Maine Medicaid Expansion Report - Dec 30 Draft

Ieas|b|||ty of Med|ca|d Lxpans|on
under the Affordab|e Care Act:

A kev|ew Subm|tted to the
Ma|ne Department of
nea|th & numan Serv|ces

Monday, December 30, 2013

1he A|exander Group, LLC
rovldence, 8.l.
hlladelphla, a.
WashlngLon, u.C.

Moloe 5tote copltol 1965
llbtoty of cooqtess, ltlots & lbotoqtopbs ulvlsloo, M, 6-AuC, 2-1

cteotloq ooJ uellvetloq looovotlve Clobol 5olotloos

"#$%&'()*(+ ,-.- "/&01'(02/&1+ "1- 314/&)56$)+ 7-8-

1ab|e of Contents

age l
1AuLL Cl CCl1Ll1S
1A8LL CI CCN1LN1S ............................................................................................... |
1A8LL CI IIGUkLS ................................................................................................ |||
LIS1 CI ACkCNMS ........................................................................................... v||
Ioreword .............................................................................................................. |x
Lxecut|ve Summary .............................................................................................. x|
8ackground ..................................................................................................................................... xl
Pow SLaLes Are uecldlng ................................................................................................................ xl
8esulLs from Lhe llnanclal Model .................................................................................................. xll
8lsk Analysls .................................................................................................................................. xlll
Concluslon ..................................................................................................................................... xlv
Sect|on I: Introduct|on ........................................................................................... 1
Cvervlew .......................................................................................................................................... 1
Medlcald ln 8rlef .............................................................................................................................. 1
1he ACA and Lhe CourL ueclslon ...................................................................................................... 2
lmporLance of leaslblllLy ................................................................................................................. 4
Sect|on II: Med|ca|d I|nance and CutcomesNat|ona| erspect|ve ....................... 7
Cvervlew .......................................................................................................................................... 7
Cfflclal uS CovernmenL lorecasL .................................................................................................... 7
lederal 8udgeL ueflclL and naLlonal uebL ..................................................................................... 10
erspecLlve from Lhe SLaLes .......................................................................................................... 16
Less lunds for vulnerable opulaLlons.......................................................................................... 19
lnadequaLe aymenL Lo rovlders ................................................................................................. 20
oor PealLh CuLcomes .................................................................................................................. 23
Sect|on III: now States Are Dec|d|ng .................................................................... 2S
WhaL SLaLes Are uolng................................................................................................................... 23
LllglblllLy ueLermlnaLlon Challenges .............................................................................................. 26
Medlcald 8eallzes LargesL lncreases wlLh Lhe ACA ....................................................................... 27
SelecLed SLaLe PlghllghLs of 8ecenL AcLlvlLy .................................................................................. 28
Sect|on IV: Ma|neCare Cverv|ew .......................................................................... 33
uemographlc lmpacL ..................................................................................................................... 33
1ab|e of Contents

age: ll
lederal Medlcal AsslsLance ercenLage (lMA) ........................................................................... 41
Malne rlvaLe PealLh lnsurance remlum rogram (Pl) ........................................................... 42
lnlLlal lssues wlLh CuallLy ............................................................................................................... 43
ollcy Changes on Lhe unlnsured and uncompensaLed Care ....................................................... 47
Sect|on V: kesu|ts of the I|nanc|a| Mode|............................................................. S1
Cvervlew of llnanclal Model ......................................................................................................... 31
opulaLlon ...................................................................................................................................... 32
llscal CosL ...................................................................................................................................... 37
l|sca| lmoact ................................................................................................................................... 63
Conc|us|on on 8esu|ts o l|nanc|a| Mooe| ....................................................................................... 67
Sect|on VI: k|sk Ana|ys|s ....................................................................................... 69
Cvervlew ........................................................................................................................................ 69
1he 8lsk lacLors Consldered .......................................................................................................... 69
overLy CrowLh 8lsk lacLor ........................................................................................................... 71
MM 8lsk lacLor .......................................................................................................................... 83
rlvaLe urop 8lsk lacLor ................................................................................................................ 93
lMA 8lsk lacLor ......................................................................................................................... 103
8esL Case / WorsL Case Scenarlos ............................................................................................... 107
Sect|on VII: Conc|us|on and Next Steps .............................................................. 119
Append|x A: Summary of Med|ca|d-Lxpans|on Dec|s|ons by the States .............. 121
Append|x 8: Methodo|ogy, Assumpt|ons, Data, and Cther 1echn|ca|
Informat|on ....................................................................................................... 131
Append|x C: key AG 1eam Members Who Contr|buted to 1h|s keport ............... 137
8|b||ography ...................................................................................................... 141
1ab|e of I|gures
age: lll
1AuLL Cl llCb8LS
llCu8L 1: 8C!LC1Lu MLulCAlu Ln8CLLMLn1 MlLLlCnS Cl L8SCnS .......................................................................................... 8
llCu8L 2: 8C!LC1Lu MLulCAlu LxLnul1u8LS ln 8lLLlCnS Cl uCLLA8S ....................................................................................... 9
llCu8L 3: MLulCAlu LxLnul1u8LS AS L8CLn1 Cl Cu ............................................................................................................ 10
llCu8L 4: 1C 10 LA8CLS1 lLuL8AL uLllCl1S 8AnkLu ln 1WC WA?S ........................................................................................... 11
llCu8L 3: CCMA8L uS uL81/ Cu 8A1lC 1C Lu CCun18lLS ..................................................................................................... 12
llCu8L 6: 1C1AL Cu1LA?S l8CM lLuL8AL CCvL8nMLn1 2011-2013 .......................................................................................... 13
llCu8L 7: CCMA8lnC MAlnL 1C 1PL nA1lCnAL AvL8ACL lC8 MA!C8 LxLnul1u8LS .................................................................... 17
llCu8L 8: S1A1L 8AnkS lC8 SLnulnC Cn 8ASlC LuuCA1lCn / MLulCAlu ..................................................................................... 18
llCu8L 9: CLn1S Cn 1PL uCLLA8 MLulCAlu A?S 8LLA1lvL 1C 8lvA1L lnSu8L8S 8? S1A1L .............................................................. 20
llCu8L 10: SuMMA8? Cl WPA1 1PL S1A1LS A8L uClnC ............................................................................................................ 23
llCu8L 11: 8C!LC1Lu CPAnCLS ln MAlnL'S ACL 8CllLL l8CM 2012 1C 2022 ........................................................................... 33
llCu8L 12: CvL81? lS A C8l1lCAL lSSuL lC8 MAlnL .................................................................................................................. 34
llCu8L 13: MAlnL CuLA1lCn Anu CvL81? 18LnuS lC8 ?LA8S 2000 - 2012 ............................................................................ 34
llCu8L 14: MAlnL CvL81? AS L8CLn1 Cl CuLA1lCn ........................................................................................................... 33
llCu8L 13: S1A1L 8? S1A1L MLAn unPLAL1P? uA?S ln LAS1 30 uA?S .......................................................................................... 36
llCu8L 16: MAlnL uPPS 8uuCL1ALL lunuS ....................................................................................................................... 37
llCu8L 17: MAlnL uPPS 8uuCL1CLnL8AL lunu CnL? ........................................................................................................ 37
llCu8L 18: MAlnLCA8L AS L8CLn1 Cl lunulnC SCu8CL .......................................................................................................... 38
llCu8L 19: L8CLn1 SLn1 Cl 8uuCL1A8? lunuS .................................................................................................................... 39
llCu8L 20: CCMA8lnC MAlnLCA8L 1C u8LlC SCPCCLS SuC81 .............................................................................................. 39
llCu8L 21: nLW LnCLAnu S1A1LS LxLnul1u8LS Cn MLulCAlu - L8CLn1 Cl 1C1AL .................................................................... 40
llCu8L 22: 1Ln ?LA8 AnnuAL 8uuCL1 C8CW1P CCMA8lSCnS .................................................................................................. 40
llCu8L 23: 1PL PlS1C8? Cl lMA ln MAlnL ........................................................................................................................... 42
llCu8L 24: L8CLn1 Cl lAMlLlLS Ln8CLLLu ln Pl ................................................................................................................. 43
llCu8L 23: MAlnL 8LAuMlSSlCn 8A1LS 8? MLulCAL A8LA ......................................................................................................... 44
llCu8L 26: S1A1L Anu MAlnLCA8L 8CC8AM WAl1LlS1S ........................................................................................................... 43
llCu8L 27: ACL 8? L1C lAClLl1? S1A1lS1lCS .............................................................................................................................. 46
llCu8L 28: MAlnLCA8L Ln8CLLMLn11C1AL MLM8L8S Anu MM ........................................................................................ 47
llCu8L 29: MAlnL unlnSu8Lu 8A1LS ...................................................................................................................................... 48
llCu8L 30: AnnuAL AvL8ACL 8C!LC1Lu C8CW1P 8A1LS .......................................................................................................... 32
llCu8L 31: MAlnL AC1uA8lAL lC8LCAS1 Cl L8SCnS ln CvL81? ............................................................................................... 33
llCu8L 32: 8ASLLlnL Ln8CLLMLn1 lC8LCAS1S .......................................................................................................................... 34
llCu8L 33: Ln8CLLMLn1 ulllL8LnCLS 8L1WLLn 8ASLLlnLS ........................................................................................................ 34
llCu8L 34: MAlnLCA8L Ln8CLLMLn1 Wl1P LxAnSlCn ............................................................................................................. 33
llCu8L 33: MAlnLCA8L Ln8CLLMLn1 Sl? 2014-13 LxAnSlCn lC8LCAS1 .................................................................................. 36
llCu8L 36: MAlnLCA8L Ln8CLLMLn1 lC8LCAS1S CCMA8lSCn .................................................................................................. 37
llCu8L 37: 1C1AL CCS1 ulllL8LnCL 8L1WLLn 8ASLLlnLS ........................................................................................................... 38
llCu8L 38: S1A1L CCS1 ulllL8LnCL 8L1WLLn 8ASLLlnLS ............................................................................................................ 39
llCu8L 39: MAlnLCA8L 1C1AL CCS1 lC8LCAS1 ......................................................................................................................... 60
llCu8L 40: LS1lMA1Lu CCS1 Cl LxAnSlCn CvL8 8ASLLlnL 1 ..................................................................................................... 60
llCu8L 41: LS1lMA1Lu CCS1 Cl LxAnSlCn CvL8 8ASLLlnL 2 ..................................................................................................... 61
llCu8L 42: 1PL ALLxAnuL8 C8Cu llnAnClAL MCuLL 8LSuL1S .................................................................................................. 62
llCu8L 43: MAlnLCA8L AS L8CLn1 Cl S1A1L CuLA1lCn ........................................................................................................ 63
llCu8L 44: MAlnLCA8L SL8vlCLS Anu 8uuCL1 C8CW1P CCMA8lSCn ........................................................................................ 64
1ab|e of I|gures
age: lv
llCu8L 43: MAlnLCA8L SL8vlCLS AS L8CLn1 Cl MAlnL S1A1L 8uuCL1 8? lunu .......................................................................... 63
llCu8L 46: MAlnLCA8L Ln8CLLLLS 1C LMLC?Lu MAlnL8S 8A1lC .............................................................................................. 66
llCu8L 47: MAlnLCA8L Ln8CLLMLn1 1C LMLC?MLn1 CCMA8lSCn .......................................................................................... 67
llCu8L 48: 8lSk lAC1C8S LxAMlnLu ....................................................................................................................................... 69
llCu8L 49: CvL81? C8CW1P 8lSk lAC1C8S ............................................................................................................................ 71
llCu8L 30: CvL81? C8CW1P 8lSk lAC1C8 CPAnCLS 1C ASSuMLu MluuLL vALuLS ...................................................................... 71
llCu8L 31: LxAnSlCn lMAC1 Cl CvL81? C8CW1P 8lSk lAC1C8S ............................................................................................ 72
llCu8L 32: 8AnCL Cl AC1uA8lAL lC8LCAS1 Cl L8SCnS ln CvL81? ........................................................................................... 73
llCu8L 33: 8AnCL Cl AC1uA8lAL lC8LCAS1 Cl CPlLu8Ln ln CvL81? .......................................................................................... 74
llCu8L 34: CvL81? 8lSk lAC1C8 lMAC1 Cn MAlnLCA8L Ln8CLLMLn1 lC8LCAS1 8ASLLlnL 1 ...................................................... 73
llCu8L 33: CvL81? 8lSk lAC1C8 lMAC1 Cn MAlnLCA8L Ln8CLLMLn1 lC8LCAS1 8ASLLlnL 2 ...................................................... 76
llCu8L 36: CvL81? 8lSk lAC1C8 lMAC1 Cn MAlnLCA8L AS L8CLn1 Cl S1A1L CuLA1lCn ......................................................... 77
llCu8L 37: CvL81? 8lSk lAC1C8 lMAC1 Cn MAlnLCA8L 1C1AL CCS1 lC8LCAS1 8ASLLlnL 1 ....................................................... 78
llCu8L 38: CvL81? 8lSk lAC1C8 lMAC1 Cn MAlnLCA8L 1C1AL CCS1 lC8LCAS1 8ASLLlnL 2 ....................................................... 79
llCu8L 39: CvL81? 8lSk lAC1C8 lMAC1 Cn 1C1AL CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 1 ................................................... 80
llCu8L 60: CvL81? 8lSk lAC1C8 lMAC1 Cn 1C1AL CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 2 ................................................... 81
llCu8L 61: CvL81? 8lSk lAC1C8 lMAC1 Cn S1A1L CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 1 ................................................... 82
llCu8L 62: CvL81? 8lSk lAC1C8 lMAC1 Cn S1A1L CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 2 ................................................... 83
llCu8L 63: MM C8CW1P 8lSk lAC1C8 ............................................................................................................................... 83
llCu8L 64: MM 8lSk lAC1C8 1C ASSuMLu MluuLL vALuLS ................................................................................................... 83
llCu8L 63: LxAnSlCn lMAC1 Cl MM 8lSk lAC1C8S ........................................................................................................... 86
llCu8L 66: MM 8lSk lAC1C8 lMAC1 Cn MAlnLCA8L 1C1AL CCS1 lC8LCAS18ASLLlnL 1 ......................................................... 87
llCu8L 67: MM 8lSk lAC1C8 lMAC1 Cn MAlnLCA8L 1C1AL CCS1 lC8LCAS18ASLLlnL 2 ......................................................... 88
llCu8L 68: MM 8lSk lAC1C8 lMAC1 Cn 1C1AL CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 1 .................................................... 89
llCu8L 69: MM 8lSk lAC1C8 lMAC1 Cn 1C1AL CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 2 .................................................... 90
llCu8L 70: MM 8lSk lAC1C8 lMAC1 Cn S1A1L CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 1 .................................................... 91
llCu8L 71: MM 8lSk lAC1C8 lMAC1 Cn S1A1L CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 2 ..................................................... 92
llCu8L 72: u8CLu 8lvA1L lnSu8AnCL 8lSk lAC1C8 .............................................................................................................. 93
llCu8L 73: 8lvA1L u8C 8lSk lAC1C8 CPAnCLS 1C ASSuMLu MluuLL vALuLS ............................................................................ 93
llCu8L 74: LxAnSlCn lMAC1 Cl 8lvA1L u8C 8lSk lAC1C8S .................................................................................................. 94
llCu8L 73: 8lvA1L u8C 8lSk lAC1C8 lMAC1 Cn Ln8CLLMLn1 8LLA1lvL 1C 8ASLLlnL 1 .............................................................. 93
llCu8L 76: 8lvA1L u8C 8lSk lAC1C8 lMAC1 Cn Ln8CLLMLn1 8LLA1lvL 1C 8ASLLlnL 2 .............................................................. 96
llCu8L 77: 8lvA1L u8C 8lSk lAC1C8 lMAC1 Cn MAlnLCA8L AS A L8CLn1 Cl S1A1L CuLA1lCn ............................................... 97
llCu8L 78: 8lvA1L u8C 8lSk lAC1C8 lMAC1 Cn 1C1AL CCS1 Cl MAlnLCA8L 8LLA1lvL 1C 8C1P 8ASLLlnLS .................................... 98
llCu8L 79: 8lvA1L u8C 8lSk lAC1C8 lMAC1 Cn 1C1AL CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 1 ........................................... 99
llCu8L 80: 8lvA1L u8C 8lSk lAC1C8 lMAC1 Cn 1C1AL CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 2 ......................................... 100
llCu8L 81: 8lvA1L u8C 8lSk lAC1C8 lMAC1 Cn S1A1L CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 1 .......................................... 101
llCu8L 82: 8lvA1L u8C 8lSk lAC1C8 lMAC1 Cn S1A1L CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 2: ......................................... 102
llCu8L 83: lMA 8lSk lAC1C8S .......................................................................................................................................... 103
llCu8L 84: lMA 8lSk lAC1C8 CPAnCLS 1C ASSuMLu Cl MluuLL vALuLS ................................................................................ 103
llCu8L 83: LxAnSlCn lMAC1 Cl lMA 8lSk lAC1C8S .......................................................................................................... 104
llCu8L 86: lMA 8lSk lAC1C8 lMAC1 S1A1L CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 1 ......................................................... 103
llCu8L 87: lMA 8lSk lAC1C8 lMAC1 S1A1L CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 2 ......................................................... 106
llCu8L 88: 8LS1 Anu WC8S1 CASL SCLnA8lCS ........................................................................................................................ 107
llCu8L 89: 8LS1 Anu WC8S1 CASL 8lSk lAC1C8 CPAnCLS 1C ASSuMLu MluuLL vALuLS .............................................................. 108
llCu8L 90: LxAnSlCn lMAC1 Cl 8LS1 CASL Anu WC8S1 CASL 8lSk lAC1C8S ............................................................................ 108
llCu8L 91: 8LS1 CASL / WC8S1 CASL 8lSk lAC1C8 lMAC1 Cn Ln8CLLMLn1 8LLA1lvL 1C 8ASLLlnL 1 ............................................. 109
1ab|e of I|gures
age: v
llCu8L 92: 8LS1 CASL / WC8S1 CASL 8lSk lAC1C8 lMAC1 Cn Ln8CLLMLn1 8LLA1lvL 1C 8ASLLlnL 2 ............................................. 110
llCu8L 93: 8LS1 CASL / WC8S1 CASL 8lSk lAC1C8 lMAC1 Cn MAlnLCA8L AS A L8CLn1 Cl S1A1L CuLA1lCn ............................. 111
llCu8L 94: 8LS1 CASL / WC8S1 CASL 8lSk lAC1C8 lMAC1 Cn 1C1AL CCS1 Cl MAlnLCA8L 8LLA1lvL 1C 8ASLLlnL 1 ......................... 112
llCu8L 93: 8LS1 CASL / WC8S1 CASL 8lSk lAC1C8 lMAC1 Cn 1C1AL CCS1 Cl MAlnLCA8L 8LLA1lvL 1C 8ASLLlnL 2 ......................... 113
llCu8L 96: 8LS1 CASL / WC8S1 CASL 8lSk lAC1C8 lMAC1 Cn 1C1AL CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 1 .......................... 114
llCu8L 97: 8LS1 CASL / WC8S1 CASL 8lSk lAC1C8 lMAC1 Cn 1C1AL CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 2 .......................... 113
llCu8L 98: 8LS1 CASL / WC8S1 CASL 8lSk lAC1C8 lMAC1 Cn S1A1L CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 1 .......................... 116
llCu8L 99: 8LS1 CASL / WC8S1 CASL 8lSk lAC1C8 lMAC1 Cn S1A1L CCS1 Cl LxAnSlCn 8LLA1lvL 1C 8ASLLlnL 2 .......................... 117
llCu8L 100: CuLA1lCn C8CW1P lAC1C8S .......................................................................................................................... 133
llCu8L 101: AC1uAL MMS L8 CA1LCC8? ........................................................................................................................ 134
llCu8L 102: ASSuMLu lMA 8A1LS .................................................................................................................................... 133

1ab|e of I|gures
age: vl

1hls age lnLenLlonally LefL 8lank

L|st of Acronyms
age: vll
LlS1 Cl AC8?Cl?MS
ACA Affordable Care AcL of 2010
AC 1he Alexander Croup
A88A Amerlcan 8ecovery and 8elnvesLmenL AcL of 2009
ASL AsslsLanL SecreLary for lannlng and LvaluaLlon, uSuPPS
8l 8alanclng lncenLlves rogram CranL
C8C Congresslonal 8udgeL Cfflce
CuC CenLers for ulsease ConLrol and revenLlon
CPl Childrens Health Insurance Program. Also known as SCHIP.
CMS u.S. CenLer on Medlcare and Medlcald Servlces
C? Calendar ?ear
LSl Lmployer-sponsored lnsurance
uSP ulsproporLlonaLe Share PosplLal
ll? lederal llscal ?ear
lMA lederal Medlcal AsslsLance ercenLage
lL lederal overLy Level
Cu Cross uomesLlc roducL
PC8S Pome and CommunlLy-8ased Servlces
Pl PealLh lnsurance remlum aymenL
L1SS Long 1erm Servlces and SupporL
MACl Modlfled Ad[usLed Cross lncome
MuPPS Malne ueparLmenL of PealLh and Puman Servlces
L|st of Acronyms
age: vlll
MMlS Medlcald ManagemenL lnformaLlon SysLems
nAS8C naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers
nll8 naLlonal lederaLlon of lndependenL 8uslness
CAuS Maines Office of Aging and Disability Services
CMS Cfflce of MalneCare Servlces
Pl Malne rlvaLe PealLh lnsurance remlum rogram
MM Average cosL, er-MonLh er-Member
SAlL Small Area lncome and overLy LsLlmaLes
Sl? SLaLe llscal ?ear
SCPl States Children Health Insurance Program. Also known as CHIP.
SA SLaLe lan AmendmenL
uSuPPS unlLed SLaLes ueparLmenL of PealLh and Puman Servlces
Ioreword
age: lx
loewoo
AlLhough an essenLlal program for Lhe poor and vulnerable, Medlcald has for years represenLed a
slgnlflcanL budgeL challenge for sLaLe governmenLs. As Lhe asslsLance program has expanded,
pollcymakers have aLLempLed Lo llmlL or reln ln fundlng Lo slow lLs growLh, yeL Loday Medlcald has
replaced k-12 education as the largest financial item in states budgets when all funds are counted.
1o lessen Lhe flscal lmpacL, governmenL offlclals have lmplemenLed numerous lnlLlaLlves, lncludlng
raLe reducLlons, managed care Lo moderaLe uLlllzaLlon, pharmaceuLlcal resLrlcLlons, and even
lmposlng co-paymenLs and cosL sharlng Lo lnLroduce personal responslblllLy. lurLher, as Lhe federal
governmenL has soughL Lo reduce lLs share of paymenL, sLaLe governmenLs have aLLempLed Lo
lncrease revenue by uslng pracLlces LhaL lncrease federal Medlcald spendlng wlLh llmlLed or no real
sLaLe conLrlbuLlon. uesplLe Lhese efforLs, Medlcald remalns a flscal challenge Lo sLaLe pollcymakers
as Lhey also grapple wlLh fundlng oLher budgeLary prlorlLles, such as educaLlon, LransporLaLlon, and
Lhe envlronmenL.
Malne ls no dlfferenL, yeL lLs case ls more acuLe. ?ears of sysLem changes, expanslons, modlflcaLlons,
and even some achlevemenLs Lo more approprlaLely serve Lhe physlcally and medlcally fraglle, have
left Medicaids growth outpacing other major budget items, such as fundlng for k-12 educaLlon,
which is necessary to achieve future economic growth and stability. Maines Medicaid system, called
MalneCare, ls sufferlng from lnadequaLe flnanclal resources Lo malnLaln currenL commlLmenLs.
1housands of persons wlLh lnLellecLual dlsablllLles are walLlng for necessary servlces Lo help Lhem
llve healLhy and safely, physlclans lack adequaLe relmbursemenL and are becomlng scarcer for
MalneCare enrollees, lnformaLlon-Lechnology sysLems are ln need of enhancemenLs, and Lhe elderly
populaLlon ls fasL growlng.
Llke mosL sLaLes, Malne ls ln Lhe mldsL of maklng a declslon wheLher or noL Lo expand Medlcald. lor
Lhose sLaLes LhaL have chosen Lo expand Medlcald, Lhe Affordable Care AcL (ACA), slgned lnLo law
ln 2010, Lransforms Lhe program from a LradlLlonal program LhaL serves Lhe mosL needy and
vulnerable Lo one LhaL provldes healLh-care coverage for everyone under Lhe lncome Lhreshold of
138 of Lhe lederal overLy level.
1o ensure LhaL Lhe SLaLe conslders all aspecLs of Lhis important decision, the State of Maines
ueparLmenL of PealLh and Puman Servlces has engaged Lhe Alexander Croup Lo prepare a feaslblllLy
sLudy and analyze Lhe complexlLles assoclaLed wlLh maklng Lhls deLermlnaLlon. ConsequenLly, Lhls
feaslblllLy sLudy ls offered Lo help pollcymakers make a more lnformed declslon based on Lhe
evldence and Lhe merlLs. AlLhough we have revlewed Lhe mosL sallenL aspecLs of expanslon Lo daLe,
new flndlngs and lnformaLlon wlll conLlnue Lo emerge LhaL may lnfluence our overall undersLandlng
of Lhe lssue.
Ioreword
age: x
Colng forward, Lhe Alexander Croup wlll revlew such daLa and may apply Lhose flndlngs Lo lmprove
our analysls and forecasLs. SubsequenLly, Lhe Alexander Croup may perlodlcally updaLe Lhls revlew
Lo reflecL such new lnformaLlon.
1hls feaslblllLy sLudy would never have maLerlallzed wlLhouL Lhe help of Mary Mayhew,
commlssloner of Maines ueparLmenL of PealLh and Puman Servlce. She and her sLaff were
lnvaluable ln asslsLlng us Lo obLaln daLa and oLher lnformaLlon necessary for our analysls. Per
deparLmenL also revlewed a drafL of Lhls sLudy. ursuanL Lo sLandard pracLlce, we lncorporaLed
Lhose recommendaLlons from Lhe deparLmenL LhaL we belleved lmproved Lhe reporL before
submlLLlng Lhls flnal verslon. Whlle we are lndeed graLeful for Lhe asslsLance of Lhe deparLmenL, Lhe
Alexander Croup Lakes full responslblllLy for all sLaLemenLs, oplnlons, evaluaLlons, and analysls
conLalned hereln. As we worked dlllgenLly Lo adhere Lo Lhe facLs, we are prepared Lo supporL every
sLaLemenL made Lhereln. lf any facLual errors are found, we Lake full responslblllLy and wlll lssue
correcLlve sLaLemenLs, lf necessary.
Lxecut|ve Summary
age: xl
Lxecut|ve Summay
uac|gouno
Maines Department of Health and Human Servlces has engaged Lhe Alexander Croup Lo prepare a
feaslblllLy sLudy and analyze Lhe complexlLles assoclaLed wlLh expandlng ellglblllLy Lo lLs Medlcald
program, l.e., MalneCare, pursuanL Lo Lhe Affordable Care AcL of 2010 (ACA).
1he Cfflce of Lhe AcLuary of Lhe u.S. ueparLmenL of PealLh and Puman Servlces predlcLs LhaL lf all
sLaLes expand ellglblllLy Lo Medlcald LoLal enrollmenL would lncrease Lo an esLlmaLed 84.8 mllllon ln
ll? 2021, for a 32.2 lncrease. 1he LoLal cosL would grow Lo $830.9 bllllon ln ll? 2021, an lncrease
of 94.4. 1he acLuarles noLed LhaL even lf only Lhose sLaLes comprlslng 63 of Lhe Medlcald
populaLlon declde Lo expand LhaL Medlcald wlll grow fasLer Lhan Cu, and Lhey predlcLed LhaL by
2020 lL would comprlse 3.2 of Cu, up from 2.8 ln 2011.
lor sLaLes, Medlcald has become Lhe largesL expendlLure when all fundlng sourceslncludlng
federalare consldered. uaLa from Lhe naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers show Medlcald
spendlng holds a subsLanLlal lead over Lhe second largesL sLaLe-budgeL caLegory, l.e., prlmary and
secondary educaLlon: 24.3 versus 20.0. Maines spending pattern preceded the national pattern
by more Lhan Len years when MalneCare overLook baslc educaLlon spendlng as a percenLage of Lhe
LoLal budgeL ln 1992. Also, Malne spends Lhe Lhlrd-hlghesL percenL of lLs LoLal budgeL on Medlcald
of all Lhe sLaLes.
llscal lssues are noL Lhe only challenge. A number of speclallzed Medlcald programs, lncludlng Lhose
ln MalneCare, have long walLlng llsLs. 1he low raLe of paymenL Lo physlclans has dlmlnlshed Lhe
number of docLors wllllng Lo accepL new Medlcald paLlenLs, and emplrlcal sLudles on healLh-care
quallLy have conslsLenLly ranked Medlcald on Lhe boLLom relaLlve Lo Medlcare and commerclal
coverage. llnally, Medlcald has hlsLorlcally favored cosLly lnsLlLuLlonal care, even ln cases where
lndlvlduals would be more approprlaLely served ln less-resLrlcLlve home- and communlLy-seLLlngs.
low States Ae Lec|o|ng
Accordlng Lo Lhe mosL recenL lnformaLlon avallable, LwenLy-Lwo sLaLes are noL expandlng ellglblllLy
for Lhelr Medlcald programs, Lhree sLaLes are currenLly undeclded, and LwenLy-flve sLaLes are
expandlng ln some form or anoLher. All 13 sLaLes LhaL have boLh a uemocraLlc governor and a
uemocraL-conLrolled leglslaLure are expandlng ellglblllLy. Cf Lhe 24 sLaLes wlLh 8epubllcan
governors and CC-conLrolled leglslaLures: 18 are noL expandlng, 2 are conslderlng, and 4 are
expandlng. 1he declslons are mlxed for Lhe remalnlng sLaLes.
1o daLe, sLaLes LhaL are expandlng are experlenclng challenges wlLh Lhelr ellglblllLy sysLems.
Powever, sLaLes are reporLlng hlgher enrollmenL ln Medlcald Lhan ln prlvaLe lnsurance slnce Lhe
Lxecut|ve Summary
age: xll
Affordable Care AcL exchanges opened CcLober 1, 2013. 1he reporL provldes brlef revlews of Lhe
experlence of 23 sLaLes and Lhe ulsLrlcL of Columbla.
8esu|ts om t|e l|nanc|a| Mooe|
1he Alexander Croup developed a cusLomlzed flnanclal model Lo forecasL enrollmenL and Lhe
assoclaLed flscal cosLs of MalneCare. 1he model assumes Lwo basellnes. 8asellne 1 assumes Lwo
programs wlll be dlsconLlnued: (1) parenLs 101 Lo 138 of lL, and (2) Lhe Chlldless AdulL Walver.
8asellne 2 assumes only Lhe Chlldless AdulL Walver wlll be dlsconLlnued.
8ecause of hlgh poverLy growLh, Lhe model predlcLs a slgnlflcanL growLh ln Lhe basellne scenarlos.
1hus, even wlLhouL expandlng ellglblllLy, MalneCare enrollmenL ls pro[ecLed Lo grow by an annual
average raLe of 2.8 for boLh basellnes. Cver nlne years, Lhls growLh raLe ls a LoLal lncrease of nearly
29, whlch would add 79,377 persons Lo Lhe enrollmenL of 276,231 ln Sl? 2023-24 for 8asellne 1
or 83,493 persons Lo Lhe enrollmenL of 292,936 ln Sl? 2023-24 for 8asellne 2.
under Lhe expanslon scenarlo, Lhe average annual growLh for enrollmenL ls 3.3 over Len years,
whlch ls LoLal lncrease of 71.3. 1hls would add 123,892 persons onLo Lhe rolls by Sl? 2023-24
compared Lo 8asellne 1 or 103,091 compared Lo 8asellne 2.
1he AC llnanclal Model shows Lhe LoLal cosL for Lhe basellnes and expanslon wlll be slgnlflcanL. lor
Lhe 8asellne 1 scenarlo, LoLal cosLs wlll lncrease on average of 3.2 per year, whlch lncreases Lhe
LoLal cosL by 66.7 over a Len-year perlod. under Lhls scenarlo, Lhe LoLal cosL for MalneCare
lncreases by $1.76 bllllon, from $2.6 bllllon ln Sl? 2013-14 Lo $4.4 bllllon ln Sl? 2023-24. lor 8asellne
2, LoLal cosLs wlll lncrease on average of 3.3 per year, whlch lncreases Lhe LoLal cosL by 70.2 over
a Len-year perlod. under Lhls scenarlo, Lhe LoLal cosL for MalneCare lncreases by $1.83 bllllon, from
$2.6 bllllon ln Sl? 2013-14 Lo $4.3 bllllon ln Sl? 2023-24.
lor Lhe expanslon scenarlo, Lhe LoLal cosL of MalneCare lncreases by $2.7 bllllon ln Sl? 2013-14 Lo
$3.3 bllllon ln Sl? 2023-24, an lncrease of 102. lor expanslon, sLaLe cosLs wlll be $33.4 mllllon Lo
$47.3 mllllon for Sl? 2014-13, dependlng on Lhe flnal lMA raLe for 10,300 chlldless adulLs because
of Lhe chlldless adulL walver. 1he sLaLe cosLs are pro[ecLed Lo grow Lo $128.1 mllllon ln Sl? 2023
24, LoLallng $832 mllllon Lo $863 mllllon over Len years. When compared Lo Lhe 8asellne 2 scenarlo,
sLaLe cosLs wlll be $13.3 mllllon Lo $23.2 mllllon ln Sl? 201413. 1hese sLaLe cosLs are pro[ecLed Lo
grow Lo $92.3 mllllon ln Sl? 202324, LoLallng $347 mllllon Lo $380 mllllon over Len years.
Malne had 22.6 lLs overall sLaLe populaLlon enrolled ln MalneCare ln Sl? 2012-13. 1hls percenLage
wlll grow Lo 23.4 and 26.9 by Sl? 2023-24 under 8asellne 1 and 8asellne 2, respecLlvely. WlLh
expanslon, however, 34.4 of Lhe overall sLaLe populaLlon wlll be enrolled ln Medlcald, or one ln
every Lhree persons. 1hese percenLages do noL lnclude Lhe approxlmaLely 43,000 lndlvlduals who
recelve parLlal beneflLs from MalneCare.
Lxecut|ve Summary
age: xlll
ln Lerms of sLaLe funds, Lhe budgeL for MalneCare servlces has been growlng fasLer Lhan Lhe resL of
Lhe sLaLe budgeL (6.0 average annual growLh versus 2.2). 1he AC llnanclal Model forecasLs LhaL
Lhe basellne average annual growLh raLe wlll be 3.1 Lo 3.3 for Lhe basellne scenarlos. Powever,
lf Malne elecLs Lo expand MalneCare ellglblllLy, Lhe forecasLed growLh raLe becomes 3.9.
1he percenLage of Lhe Ceneral lund budgeL dedlcaLed Lo MalneCare servlces ls pro[ecLed Lo grow
from 24.2 ln Sl? 201213 Lo 33.9 and 34.9 ln Sl? 202324 under Lhe basellne scenarlos. under
Lhe expanslon scenarlo, however, MalneCare wlll requlre 36.4 of Lhe Ceneral lund budgeL. lor Lhe
overall budgeL, lncludlng federal funds, MalneCare wlll requlre 43.9 of Lhe LoLal budgeL under
expanslon ln Sl? 2023-24 as opposed Lo 38.6 under Lhe 8asellne 1 scenarlo.
Cne qulck way Lo evaluaLe Lhe economlc lmpacL ls Lo compare MalneCare enrollmenL Lo
employmenL. ln Sl? 201213, Lhe raLlo was 1 Lo 1.9, meanlng LhaL each person on MalneCare was
supporLed by 1.9 employed persons. 1haL raLlo wlll drop Lo 1 Lo 1.4 ln 2020 under Lhe expanslon
scenarlo.
8|s| Ana|ys|s
1he scenarlos generaLed by Lhe flnanclal model are based on a number of key assumpLlons on values
of facLors LhaL wlll deLermlne whaL Lrends wlll prevall ln Lhe fuLure. Lach value chosen was ln Lhe
mlddle of an expecLed range of posslblllLles. 1here ls rlsk, however, LhaL Lhe acLual values LhaL wlll
be reallzed ln Lhe fuLure wlll fall Loward elLher end of Lhe ranges as opposed Lo ln Lhe mlddle. Low-
end values are deflned as Lhose values LhaL would cause enrollmenL and cosLs Lo be lower Lhan
forecasLed. Plgh-end values are Lhose values LhaL would cause enrollmenL and cosL Lo be more Lhan
forecasLed.
lour rlsk facLors chosen Lo be analyzed are Lhe poverLy growLh raLes, MM growLh raLes,
lndlvlduals wlLh prlvaLe lnsurance loslng coverage (prlvaLe drop), and lMA raLe changes. ln
addlLlon, a besL case scenarlo and a worsL-case scenarlo were run, assumlng LhaL Lhe Lhree of Lhose
four rlsk facLors wlll have values LhaL fall on elLher Lhe low-end or hlgh-end of Lhelr respecLlve
ranges.
varlance ln Lhe poverLy growLh rlsk facLor would cause enrollmenL for Lhe basellne scenarlos Lo vary
from -6.8 Lo +7.3 off Lhe mlddle by Sl? 2023-24, and lL would cause Lhe sLaLe cosL over Lhe Len
years for Lhe basellnes Lo vary from -3.3 Lo +3.7 off Lhe mlddle. 1oLal expanslon enrollmenL would
vary from 118,836 Lo 133,301 ln Sl? 2023-24 measured from 8asellne 1 or from 99,398 Lo 111,073
ln Sl? 2023-24 measured from 8asellne 2. SLaLe cosLs over Len years for Lhe expanslon would vary
from $801.1 mllllon Lo $863 mllllon relaLlve Lo 8asellne 1 or $328.6 mllllon Lo $367 mllllon relaLlve
Lo 8asellne 2.
varlance ln Lhe er Member er MonLh (MM) cosL rlsk facLor would cause Lhe sLaLe cosL of Lhe
basellne scenarlos Lo vary from -3.3 Lo +3.9 off Lhe mlddle over Lhe Len years. 1he Len-year sLaLe
Lxecut|ve Summary
age: xlv
cosL for Lhe expanslon would vary from $773.8 mllllon Lo $894 mllllon measured from 8asellne 1 or
from $308.1 mllllon Lo $389.9 mllllon measured from 8asellne 2.
varlance ln Lhe prlvaLe drop rlsk facLor would cause Lhe expanslon enrollmenL Lo vary from 117,830
Lo 146,023 by Sl 2023-24. SLaLe cosLs over Len years for Lhe expanslon would vary from $788.6
mllllon Lo $943 mllllon relaLlve Lo 8asellne 1 or from $304.4 mllllon Lo $660.4 mllllon relaLlve Lo
8asellne 2.
varlance ln Lhe lMA rlsk facLor would cause Lhe sLaLe cosL of Lhe basellne scenarlos Lo vary from
-9.2 Lo +1.7 off Lhe mlddle over Lhe Len years. SLaLe cosLs over Len years for Lhe expanslon would
vary from $788 mllllon Lo $2.3 bllllon relaLlve Lo 8asellne 1 or from $333 mllllon Lo $2.2 bllllon
relaLlve Lo 8asellne 2.
1he besL-case scenarlo assumed low-end values for Lhe followlng rlsk facLors: poverLy growLh,
MM growLh, and prlvaLe drop. 1he worsL-case scenarlo assumed hlgh-end values for MM
growLh, prlvaLe drop, and lMA. varlance ln Lhe besL case / worsL-case scenarlos would cause
enrollmenL for Lhe basellne scenarlos Lo vary from -6.8 Lo 0 off Lhe mlddle by Sl? 2023-24, and
lL would cause Lhe Len-year sLaLe cosLs for Lhe basellnes Lo vary from -8.7/-8.8 Lo +7.7 off Lhe
mlddle. 1oLal expanslon enrollmenL would vary from 111,239 Lo 146,023 ln Sl? 2023-24 relaLlve Lo
8asellne 1 or from 91,781 Lo 123,223 ln Sl? 2023-24 relaLlve Lo 8asellne 2. SLaLe cosLs over Len years
for Lhe expanslon would vary from $707.1 mllllon Lo $3.1 bllllon relaLlve Lo 8asellne 1 or from $432.2
mllllon Lo $2.8 bllllon relaLlve Lo 8asellne 2.
Conc|us|on
1he AC llnanclal Model demonsLraLes LhaL lL wlll be challenglng for Malne Lo afford MalneCare ln
Lhe fuLure even wlLhouL expanslon. Clven currenL Lrends, MalneCare wlll comprlse larger shares of
Maines General Fund budgets. Expanding eligibility will only exacerbate the trend, whereby
MalneCare wlll comprlse 36.4 of Lhe Ceneral lund budgeL ln Len years. ln addlLlon, rlsk analysls
shows LhaL ln Lhe besL-case scenarlo, expanslon of Medlcald ellglblllLy would sLlll cosL Lhe sLaLe $432
mllllon Lo $707 mllllon over Lhe nexL Len years compared Lo 8asellne 1 and 8asellne 2, respecLlvely.
1he worsL-case scenarlo, however, would cosL Lhe sLaLe beLween $2.8 bllllon Lo $3.1 bllllon over Lhe
nexL Len years.
1he more presslng needs are resLrucLurlng and sLreamllnlng Lo make MalneCare more efflclenL and
Lo dellver beLLer quallLy ouLcomes. Whlle healLh-care access and lmproved healLh ouLcomes remaln
an lmperaLlve, expanslon of Medlcald may noL be Lhe besL pollcy cholce Lo achleve Lhose goals.
CLher vlable alLernaLlves may allow Malne Lo lmprove access and quallLy whlle prlorlLlzlng needs
and savlng Lax dollars. ConsequenLly, Malne needs a sLaLe-based soluLlon wlLh flexlblllLy from Lhe
federal governmenL LhaL focuses on access, Lransparency, quallLy, personal responslblllLy, and
efflclency. 1haL alLernaLlve would offer execuLlve and leglslaLlve pollcymakers greaLer budgeLary
cerLalnLy, and allow Lhem Lo focus on oLher flscal and pollcy prlorlLles.
Sect|on I: Introduct|on

age: 1
Sect|on l: lntoouct|on
Cvev|ew
The Alexander Group (AG) was asked to revlew Lhe proposed Medlcald expanslon currenLly offered
under Lhe Affordable Care AcL and offer a feaslblllLy sLudy for Malne. MalneCare
1
ls Lhe Medlcald
program for Lhe SLaLe of Malne. 1he Affordable Care AcL of 2010 (ACA)
2
mandaLes LhaL sLaLes expand
ellglblllLy for Lhelr Medlcald programs Lo lnclude all persons wlLh lncomes equal Lo or less Lhan 133
of Lhe lederal overLy Level (lL)
3
as deflned by Lhe law, plus a 3 lncome dlsregard effecLlvely
exLendlng ellglblllLy Lo 138 of lL ($13,836 for an lndlvldual, $32,499 for a famlly of four ln 2013.)
1he u.S. Supreme CourL ruled LhaL Congress exceeded lLs auLhorlLy ln mandaLlng Lhe expanslon of
ellglblllLy, Lhus glvlng each sLaLe Lhe cholce on wheLher lL wanLs Lo expand ellglblllLy as deflned by
Lhe ACA.
Meo|ca|o |n u|e
Medlcald
4
ls a cooperaLlve program beLween sLaLes and Lhe federal governmenL Lo provlde healLh
care beneflLs Lo low-lncome lndlvlduals who also meeL ellglblllLy requlremenLs of predeflned
caLegorles. ln order Lo recelve federal maLchlng funds, sLaLes musL provlde beneflLs for numerous
mandaLory ellglblllLy caLegorles, whlch are ofLen summarlzed as pregnanL women, lnfanLs and
chlldren, low-lncome famllles, dlsabled lndlvlduals, and Lhe elderly. Lach mandaLory populaLlon has
lLs own seL of ellglblllLy rules.
SLaLes may also recelve federal maLchlng funds for programs LhaL cover opLlonal caLegorles of
lndlvlduals, and Lhere ls conslderable varlaLlon and complexlLy ln how Lhese opLlonal caLegorles are
deflned. lederal law furLher provldes for walvers Lo allow sLaLes some flexlblllLy ln deslgnlng
programs ouLslde currenL program parameLers. 1hese walvers requlre approval of Lhe u.S.
ueparLmenL of PealLh and Puman Servlces (uSuPPS) ln order Lo recelve federal maLchlng funds.
SLaLes also are allowed Lo modlfy Lhelr Medlcald SLaLe lan (Lhe conLracL beLween Lhe sLaLe and Lhe
lederal governmenL that describes the states Medicaid program) through something called the

1
As used ln Lhls reporL, MalneCare lncludes all means-LesLed medlcal asslsLance programs admlnlsLered by Lhe Malne ueparLmenL
of PealLh and Puman Servlces, lncludlng CubCare.
2
1he aLlenL roLecLlon and Affordable Care AcL, ubllc Law no. 111-148, was amended by Lhe PealLh Care and LducaLlon
8econclllaLlon AcL of 2010, ubllc Law no. 111-132, and ls referred Lo ln Lhls sLudy as Lhe Affordable Care AcL (ACA).
3
1he u.S. ueparLmenL of PealLh and Puman Servlces annually publlshes poverLy guldellnes ln Lhe lederal 8eglsLer for
admlnlsLraLlve purposes of deLermlnlng ellglblllLy for varlous federal programs. 1hese guldellnes are ofLen referred Lo as Lhe
lederal overLy Level (lL).
4
LnacLed ln 1963, Medlcald ls found ln 1lLle xlx of Lhe Soclal SecurlLy AcL. 1he 8alanced 8udgeL AcL of 1997, ubllc Law 103-33,
established the State Childrens Health Insurance Program (SCHIP), which became known as the Childrens Health Insurance
rogram (CPl) afLer March 2009. lound ln 1lLle xxl of Lhe Soclal SecurlLy AcL, lL ls common Lo use CPl and SCPl
lnLerchangeably. CfLen, and ln mosL conLexLs, CPl ls consldered parL of Medlcald.

age: 2
SLaLe lan AmendmenL (SA) process. SAs allow sLaLes Lo requesL baslc program changes, make
correcLlons, or send Lhe federal governmenL updaLes on Lhelr programs. AlLhough walvers allow for
more flexlblllLy Lo LesL new and lnnovaLlve models of care or new ways Lo dellver care, boLh Lhe
walver and Lhe SA are referred Lo as Lhe legal auLhorlLy sLaLes possess Lo change Lhelr Medlcald
programs.
3

SLaLe parLlclpaLlon ln Medlcald ls opLlonal, buL all sLaLes do parLlclpaLe.
6
1he federal governmenL
provldes maLchlng funds vla a formula uslng a Lhree year average of sLaLe per caplLa lncome
7
, known
as Lhe lederal Medlcal AsslsLance ercenLage (lMA). SLaLes wlLh lower per caplLa lncomes relaLlve
Lo Lhe naLlonal average recelve hlgher lMAs whlle sLaLes wlLh hlgher per caplLa lncome recelve
lower lMAs. Powever, no sLaLe recelves less Lhan flfLy percenL. Cenerally, lMAs vary from year-
Lo-year based noL only on annual flucLuaLlons of per caplLa lncome buL also due Lo changes ln
lederal law.
8

1|e ACA ano t|e Cout Lec|s|on
1he ACA ls a complex plece of leglslaLlon havlng Len separaLe LlLles LhaL comprlse 907 pages ln Lhe
consolldaLed verslon publlshed by Lhe u.S. Pouse Cfflce of Lhe LeglslaLlve Counsel for Lhe use of lLs
aLLorneys and lLs cllenLs. ln lLs lmplemenLaLlon, lL has generaLed Lhousands of pages of federal
regulaLlons, and lL lmpacLs Medlcare
9
, Medlcald, Lhe sLaLes LhaL admlnlsLer Medlcald, healLh-care
provlders, healLh-care devlce manufacLurers, and poLenLlally every clLlzen because of Lhe

3
Lach Llme a sLaLe wanLs Lo make changes Lo lLs exlsLlng Medlcald sysLem, lL musL go Lhrough Lhese admlnlsLraLlve processes wlLh
Lhe lederal governmenL. 1hese processes are ofLen Llmes Ledlous, laborlous, and ouLmoded.
6
Arlzona was Lhe lasL sLaLe ln Lhe unlon Lo lmplemenL Medlcald, dolng so ln 1982, 17 years afLer resldenL Lyndon !ohnson slgned
Lhe program lnLo law.
7
er caplLa lncome ls maLhemaLlcally deLermlned by dlvldlng LoLal lncome by LoLal populaLlon.
8
A few examples lnclude changes Lo Lhe lMA ln Lhe aLlenL roLecLlon and Affordable Care AcL (ACA, .L. 111-148 as amended),
federal deflclL reducLlon proposals orlglnally offered ln laLe 2011, whlch would amend Lhe lMA raLe, and Lhe dlsasLer-relaLed
lMA ad[usLmenL.
9
Medlcare and Medlcald should noL be confused. Medlcare ls a federally run program Lo provlde baslc healLh care coverage for
mosL Amerlcans age 63 or older and cerLaln groups of dlsabled lndlvlduals under 63 who are recelvlng soclal securlLy beneflLs.
Medlcald ls a federal program Lo provlde supporL Lo Lhe sLaLes Lo run means-LesLed programs for speclflc caLegorles of low lncome
lndlvlduals and ls Lhe sub[ecL of Lhls sLudy and descrlbed ln greaLer deLall LhroughouL Lhls reporL. More formerly LlLled PLAL1P
lnSu8AnCL lC8 1PL ACLu Anu ulSA8LLu found ln 1lLle xvlll of Lhe Soclal SecurlLy AcL, Medlcare was creaLed as parL of Lhe Soclal
SecurlLy AmendmenLs of 1963 Lo provlde healLh care coverage for aged persons Lo complemenL reLlremenL, survlvors, and
dlsablllLy beneflLs under 1lLle ll of Lhe Soclal SecurlLy AcL. ln 1973, Lhe program was expanded Lo lnclude groups of lndlvlduals
wlLh dlsablllLles, lncludlng Lhose enLlLled Lo Soclal SecurlLy or 8allroad 8eLlremenL dlsablllLy cash beneflLs for aL leasL 24 monLhs
and mosL persons wlLh end-sLage renal dlsease. 1he rogram was expanded agaln ln 2001 and 2010 Lo oLher small groups of
lndlvlduals. AlLhough Medlcare has an esLabllshed 1rusL lund LhaL lnlLlally was Lo be funded prlmarlly from revenues collecLed
from payroll deducLlons, currenLly aL 2.9 of earnlngs, Lhls ls no longer Lhe case. Accordlng Lo Lhe 201J Aooool kepott of tbe
8ootJs of 1tostees of tbe leJetol nospltol losotooce ooJ leJetol 5opplemeototy MeJlcol losotooce 1tost looJ, LoLal expenses for
Calendar ?ear 2012 were $374.2 bllllon, buL revenue from payroll deducLlons equaled only $203.7 bllllon. 1he 1rusL lund recelved
$214.4 bllllon from general revenue of Lhe federal governmenL, $8.4 mllllon from Lransfers from Lhe sLaLes, and lL sLlll ran a $37.2
bllllon deflclL. Accordlng Lo Lhe reporL, Lhe 1rusL lund ended Lhe year wlLh asseLs of $287.6 bllllon, whlch are mosLly held as
1reasury noLes and bonds guaranLeed by Lhe federal governmenL. 1here were 42.1 mllllon aged persons and 8.4 mllllon dlsabled
persons on Medlcare for Lhe calendar year.

age: 3
wldespread lmpacL on Lhe healLh-care lndusLry and Lhe many changes Lo Lhe lnLernal 8evenue Code
LhaL creaLe new Laxes and penalLles. 1he lmpacL on Lhe sLaLes ls qulLe exLenslve, requlrlng sLaLes Lo
deLermlne Medlcald ellglblllLy by a new Modlfled Ad[usLed Cross lncome (MACl) meLhodology, Lo
make numerous sysLem changes Lo Lhelr Medlcald ManagemenL lnformaLlon SysLem (MMlS) for
boLh clalms and provlders, and Lo adopL a new naLlonal codlng sysLem, Lo name a few.
10

Title II, of the ACA, called the Role of Public Programs, is a section of the law that makes significant
changes Lo Medlcald. MosL lmporLanL for Lhls sLudy ls Lhe pre-Supreme CourL rullng mandaLe LhaL
sLaLes musL expand Medlcald ellglblllLy Lo lnclude all persons aL 138 of lL or below. When Lhe
ACA was passed lnLo law, no sLaLe covered all persons aL or below LhaL deflned lncome level. 1he
penalLy for sLaLes chooslng noL Lo expand would be Lhe loss of all federal maLchlng funds.
1o Lhe crafLers of Lhe ACA, Medlcald was an lmporLanL plece of Lhe law. lL was Lhe chosen
mechanlsm Lo provlde healLh lnsurance for all lndlvlduals aL 138 of lL or below as parL of a plan
Lo provlde healLh care for all Amerlcans. 1he ACA lnLroduces new sLandards for employer-based
lnsurance plans, and lL mandaLed Lhe creaLlon of healLh care lnsurance exchanges, elLher federally
or sLaLe run. 1hese exchanges are lnLended Lo help lndlvlduals, famllles, and small buslnesses obLaln
healLh care lnsurance coverage.
1he ACA has numerous flnanclal lncenLlves and dlslncenLlves. lor example, employers wlLh flfLy or
more employees wlll be penallzed lf Lhey do noL provlde healLh care beneflLs. noLwlLhsLandlng some
excepLlons, lndlvlduals wlLhouL healLh lnsurance as deflned by Lhe law would be sub[ecL Lo a Lax
penalLy. lL provldes Lax lncenLlves for persons wlLh lncome beLween 100 and 400 of lL Lo
purchase healLh care lnsurance. lL provldes slgnlflcanLly hlgher levels of lMAs for sLaLes Lo help
cover Lhe cosL of new populaLlons enrolllng ln Medlcald, and lL penallzes sLaLes who do noL expand
by denylng Lhem federal asslsLance for Medlcald.
1wenLy-slx sLaLes, several lndlvlduals, and Lhe naLlonal lederaLlon of lndependenL 8uslness broughL
sulL ln lederal ulsLrlcL CourL, challenglng Lhe consLlLuLlonallLy of Lwo aspecLs of Lhe law: Lhe
lndlvldual mandaLe and Lhe requlremenL LhaL sLaLes musL expand Lhelr Medlcald program.
Cn !une 28, 2012, Lhe Supreme CourL lssued lLs declslon ln Notloool leJetotloo of loJepeoJeot
8osloess v. Sebellus (Nll8 v. 5ebellos).
11
1he lssues were separaLely addressed. ln a 3-4 declslon, Lhe
CourL ruled LhaL Lhe lndlvldual mandaLe penalLy was noL a penalLy, as deflned by Lhe law, buL raLher
a Lax for consLlLuLlonal purposes and Lhus was consLlLuLlonal under Lhe general Laxlng power of

10
1he Amerlcan AcLlon lorum provldes one calculaLlon on Maines regulatory impact to be upwards of $119 million dollars through
CcLober 2012 requlrlng Lhe equlvalenL of 97 workers Lo deal wlLh Lhe new work mandaLed by Lhe ACA. See Sam 8aLklns, SLaLe
by SLaLe lmpacL of ACA 8egulaLlons, Amerlcan AcLlon lorum, CcLober 2012, accessed aL:
hLLp://amerlcanacLlonforum.org/slLes/defaulL/flles/ACA_regs.pdf.
11
Notloool leJetotloo of loJepeoJeot 8osloess v. 5ebellos, 367 u.S.11-393, !une 2012.

age: 4
Congress. ln a 7-2 declslon, however, Lhe CourL ruled ln favor of Lhe clalmanLs saylng LhaL Lhe
requlremenL LhaL sLaLes expand Medlcald was unconsLlLuLlonal.
ln sLrlklng down Lhe mandaLory Medlcald expanslon
requlremenL, Lhe CourL underscored Lhe facL LhaL Lhe Medlcald
program was esLabllshed Lo asslsL vulnerable clLlzens, deflned as
pregnanL women, chlldren, needy famllles, Lhe bllnd, Lhe
elderly, and the disabled, in obtaining medlcal care. Whlle lL ls
common for Congress Lo place llmlLaLlons on federal fundlng,
Lhe CourL has ruled over Lhe years LhaL Lhe naLure of Lhe
llmlLaLlons musL malnLaln a volunLary acLlon on Lhe parL of Lhe
sLaLes or else lL rlsks vlolaLlng Lhe sLaLe-federal relaLlonshlp
guaranLeed by Lhe ConsLlLuLlon. 1he followlng quoLe from Lhe
declslon summarlzes Lhe legal loglc.
1betefote, lf 5totes teolly bove oo cbolce otbet tboo to occept tbe pockoqe, tbe offet ls
coetclve, ooJ tbe cooJltloos coooot be sostoloeJ ooJet tbe speoJloq powet. . . . lo som, lt ls
petfectly cleot ftom tbe qool ooJ sttoctote of tbe AcA tbot tbe offet of tbe MeJlcolJ
xpoosloo wos ooe tbot cooqtess ooJetstooJ oo 5tote coolJ tefose. 1be MeJlcolJ
xpoosloo tbetefote exceeJs cooqtess' speoJloq powet ooJ coooot be lmplemeoteJ.
12

1he effecL of Lhe courL declslon ln Nll8 v. 5ebellos ls LhaL sLaLes have a cholce on wheLher or noL Lo
Lransform Lhelr Medlcald program from a program Lo asslsL mandaLory and opLlonal caLegorles of
lndlvlduals lnLo a program Lo provlde healLh-care coverage for everyone under Lhe federally
esLabllshed lncome level, and Congress ls prohlblLed from penallzlng sLaLes LhaL decllne Lhe offer.
lmootance o leas|b|||ty
1he declslon Lo expand ellglblllLy for Medlcald lnvolves mulLlple layers of complexlLles. MalneCare
ls very complex as ls Lhe ACA and Lhe healLh care lndusLry lLself, especlally as conflgured ln Lhe
unlLed SLaLes. ln addlLlon, MalneCare ls [usL one parL of a larger welfare asslsLance sysLem,
compoundlng Lhe complexlLy. Cverlaylng Lhese complexlLles are a fundamenLal pollcy conLroversy
over whaL klnd of healLh care sysLem can besL provlde for socleLy, noL only ln regard Lo provldlng
healLh care buL also on lLs lmpacL on Lhe economy. 1he oplnlons on Lhe maLLer vary wldely, ranglng
from Lhose who prefer pure markeL forces Lo Lhose who advocaLe for a command sysLem LoLally run
by Lhe governmenL.
13
1he quesLlon has become hlghly pollLlclzed, as expecLed, buL Lhe pollLlclzaLlon

12
lbld, pp. 33 and 46.
13
1o read opposlng vlews of a free markeL sysLem and a slngle payer governmenL sysLem, See u. Lrlc Schansberg, Lnvlslonlng a
lree MarkeL ln PealLh Care, coto Iootool. vol. 31. no.1 (2011) and Pow Slngle-ayer PealLh SysLem 8eform lmproves CuallLy.
ur. Cordon Schlff and Lhe hyslclans for a naLlonal PealLh rogram (nP) Worklng Croup on CuallLy. Adapted from A Better
CuallLy AlLernaLlve: Slngle-Payer Health System Reform, Iootool of tbe Ametlcoo MeJlcol Assoclotloo, SepLember 1994. Accessed
aL: www.pnhp.org/facLs/quallLy.pdf.
AlLhough Lhe Supreme CourL
ln nll8 v Sebellus declded
LhaL sLaLes possess a cholce
Lo expand or noL, Lhe
expanslon provlslon ln Lhe
ACA sLlll fundamenLally
Lransforms Lhe program from
one LhaL covers Lhe mosL
vulnerable Lo one coverlng all
clLlzens under 138 of Lhe
federal poverLy level.

age: 3
can become problemaLlc lf pollcymakers begln Lo lgnore facLs and emplrlcal flndlngs ln favor of
phllosophlcal noLlons.
1he expanslon of Medlcald ellglblllLy per Lhe ACA allgns well wlLh Lhose lndlvlduals who have
phllosophlcal leanlngs Loward governmenL-run sysLems, and from Lhe very beglnnlng lL became
pollLlcally dlvlslve. 1he purpose of Lhls sLudy, however, ls Lo provlde facLual, analyLlcal, and
emplrlcally-based evldence Lo help Lhe Covernor and pollcymakers undersLand Lhe poLenLlal
flnanclal, operaLlonal, and performance lmpllcaLlons and challenges LhaL wlll have longsLandlng
effecLs on Lhe economlc fuLure of Lhe SLaLe of Malne and lLs clLlzens.


age: 6


Sect|on II: Med|ca|d I|nance and Cutcomes Nat|ona| erspect|ve

age: 7
Sect|on ll: Meo|ca|o l|nance ano Cutcomeslat|ona| lesoect|ve
Cvev|ew
1hls secLlon provldes a hlgh-level overvlew of Lhe flnances, ouLcomes, and speclal lssues relaLlng Lo
Medlcald programs from a naLlonal perspecLlve as well as Lhe vlew from Lhe sLaLes, wlLh a speclal
emphasls on Lhe SLaLe of Malne.
C|c|a| bS Covenment loecast
1he Cfflce of Lhe AcLuary of Lhe u.S. ueparLmenL of PealLh and Puman Servlces annually publlshes
an acLuarlal reporL on Medlcald LhaL provldes a forecasL on boLh enrollmenL and Medlcald cosLs.
Whlle Lhere are compeLlng forecasLs avallable, and perhaps some may ulLlmaLely prove Lo be more
accuraLe, Lhe offlclal forecasL ls noneLheless approprlaLe Lo use for Lhe purpose of obLalnlng a
plcLure of how enrollmenL and cosLs wlll Lrack and Lrend ln Lhe fuLure. Clearly, Lhe predlcLlons may
noL all Lurn ouL Lo be compleLely accuraLe, buL forecasLlng ls noL an exacL sclence and lL would be
dlfflculL Lo know whlch oLher forecasLs may be more rellable.
14

An lmporLanL challenge faced by Lhe uSuPPS acLuarles ln produclng Lhls reporL
13
was deLermlnlng
Lhe number of sLaLes LhaL would declde Lo expand ellglblllLy pursuanL Lo Lhe ACA. 1hey resolved Lhe
issue by assuming 55% of potentially newly eligible enrollees reside in States that would expand
Medlcald ellglblllLy ln 2014 and LhaL 63 reslde ln SLaLes LhaL would expand ellglblllLy ln 2013 and
later years. Thus, three scenarlos were creaLed: (1) no sLaLes expand pursuanL Lo Lhe ACA (labeled
as the oo expoosloo scenario), (2) some states comprising ultimately 65% of the eligible population
expand (labeled the boselloe scenario), and (3) all states expand (labeled the foll expoosloo
scenarlo).
As shown on Lhe charL ln I|gure 1,
16
Lhe Cfflce of Lhe AcLuary forecasLs LhaL Lhe Medlcald enrollmenL
wlll expand from 33.7 mllllon ln lederal llscal ?ear (ll?) 2011 Lo 77.9 mllllon ln ll? 2021 under Lhe
basellne scenarlo, whlch ls a 39.8 lncrease. under foll expoosloo, LoLal enrollmenL would lncrease
Lo an esLlmaLed 84.8 mllllon ln ll? 2021, for a 32.2 lncrease.

14
lorecasLlng allows sLaLes Lo ad[usL fuLure expecLaLlons based on pasL and or recenL performance.
13
Cfflce of Lhe AcLuary, CenLers for Medlcare & Medlcald Servlces, unlLed SLaLes ueparLmenL of PealLh & Puman Servlces, 2012
Actootlol kepott oo tbe lloooclol Ootlook fot MeJlcolJ, by ChrlsLopher !. 1ruffer, l.S.A., !ohn u. klemm, h.u., A.S.A., M.A.A.A.
ChrlsLlan !. Wolfe, A.S.A., kaLhryn L. 8ennle and !esslca l. Shuff. 2012. Accessed aL: hLLp://medlcald.gov/Medlcald-CPl-rogram-
lnformaLlon/8y-1oplcs/llnanclng-and-8elmbursemenL/uownloads/medlcald-acLuarlal-reporL-2012.pdf
16
lbld, p. 40.

age: 8
Accordlng Lo Lhe acLuarlal reporL, Lhe LoLal program cosL of Medlcald ls pro[ecLed Lo lncrease by 86
from $427.4 bllllon ln ll? 2011 Lo $796 bllllon ln ll? 2021 under Lhe boselloe scenarlo. Powever, lL
would grow Lo $830.9 bllllon ln ll? 2021, under Lhe foll expoosloo scenarlo, whlch ls nearly double
an lncrease of 94.4. 1he forecasLed growLh of Lhe Lhree scenarlos are lllusLraLed ln Lhe charL ln
I|gure 2.
17

As ls obvlous from sLudylng Lhe prevlous Lwo charLs, Lhe expoosloo
populaLlon cannoL explaln Lhe enLlre lncrease ln Lhe expendlLure
growLh. 1he acLuarles ldenLlfled whaL Lhey called Lhe mosL
lmporLanL Lhree causal facLors: expanslon of Lhe ellglble populaLlon,
lnflaLlonary pressures wlLhln Lhe healLh-care lndusLry, and
utilization. To quote from the report: uurlng 2012 Lhrough 2021,
Medlcald expendlLure growLh ls pro[ecLed Lo be 6.4 per year on
average, 1.1 percenLage polnLs hlgher Lhan lL would be lf Lhe
Affordable Care AcL lmpacLs were excluded (3.3 average
growLh).
18

17
lbld, p. 39.
18
lbld, p. 42.
"#$%&' () *&+,'-.'/ 0'/#-1#/ 23&+445'3. 0#44#+36 +7 *'&6+36
Accordlng Lo Lhe 2012
uSuPPS AcLuarlal 8eporL
Lhe LoLal program cosL of
Medlcald, lf all sLaLes
expand, ls pro[ecLed Lo
nearly double from $427.4
bllllon ln ll? 2011 Lo
$830.9 bllllon ln ll? 2021,
an lncrease of 94.4.

age: 9
Whlle Lhe pro[ecLed growLh may be sLarLllng Lo some, uSuPPS acLually lowered lLs forecasL
significantly from its 2011 report for the following reasons in order of importance: (1) states
exLenslve efforLs Lo lower cosLs and reduce paymenLs ln 2012 were greaLer Lhan anLlclpaLed, and
Lhese reducLlons were lncorporaLed lnLo Lhe forecasL, (2) 1he acLuarlal reporL reduced lLs esLlmaLes
on Lhe number of sLaLes LhaL would expand pursuanL Lo Lhe ACA, and (3) uSuPPS ls expecLlng slower
overall healLhcare expendlLure growLh.
19

1he reporL furLher compares Medlcald growLh Lo Lhe Cross uomesLlc roducL (Cu), whlch ls
produced by Lhe u.S. 8ureau of Lconomlc Analysls and measures Lhe LoLal markeL values of all flnal
goods and servlces produced wlLhln u.S. borders. Medlcald, boLh ln federal and sLaLe resources, has
been requlrlng sLeadlly more economlc resources over Lhe years: ln 1970, lL represenLed 0.3 of
Cu, ln 1980, 0.9, ln 1990, 1.2, ln 2000, 2.1, and ln 2011, 2.8.
1he acLuarles noLed LhaL even lf only Lhose sLaLes comprlslng 63 of
Lhe Medlcald populaLlon declde Lo expand LhaL Medlcald wlll grow
fasLer Lhan Cu, and Lhey predlcLed LhaL by 2020 lL would comprlse
3.2 of Cu, up from 2.8 ln 2011. 1he reporL also noLed LhaL whlle
Medlcald expendlLures have decllned somewhaL from earller
pro[ecLlons, Lhey are sLlll pro[ecLed Lo lncrease aL an average annual

19
lbld, pp. 44-43.
"#$%&' 8) *&+,'-.'/ 0'/#-1#/ 29:'3/#.%&'6 #3 ;#44#+36 +7 <+441&6
8y 2020, Medlcald wlll
reach 3.2 of Cu wlLh
only a parLlal expanslon
by Lhe sLaLes
represenLlng 63 of Lhe
Medlcald populaLlon.

age: 10
raLe of 6.4 per year Lhrough 2021. Cu, however, ls anLlclpaLed Lo grow annually by only 3. Lven
Lhls assumpLlon may be opLlmlsLlc because Cu has noL grown annually by 3 slnce prlor Lo Lhe
2007 recesslon. 1he charL shown ln I|gure 3 lllusLraLes how Medlcald expendlLures have been
ouLpaclng Cu.
20

leoea| uuoget Le|c|t ano lat|ona| Lebt
lorLy-elghL sLaLes, lncludlng Malne, have consLlLuLlonal or sLaLuLory provlslons requlrlng balanced
budgeLs, and Lhe Lwo wlLhouL such provlslons have balanced Lhelr budgeLs ln pracLlce.
21
1he federal
governmenL, however, has no such consLlLuLlonal resLrlcLlon, and ln pracLlce lL has noL exerclsed Lhe
discipline to balance the budget on a consistent basis since the 1920s, with two exceptions. From
ll?s 1947 Lhrough 1960, Lhe federal governmenL ran surpluses half Lhe Llme and Lhe aggregaLed

20
lbld, p. 30. lor 2013, healLh care spendlng growLh ls pro[ecLed Lo remaln under 4 because of Lhe slugglsh economlc recovery,
conLlnued lncreases ln cosL-sharlng requlremenLs for Lhe prlvaLely lnsured, and slower growLh for Medlcare and Medlcald
spendlng. SLarLlng ln 2014, however, growLh ln naLlonal healLh spendlng wlll acceleraLe Lo 6.1, reflecLlng expanded lnsurance
coverage and growLh Lhrough Lhe ACA, Lhrough elLher Medlcald or Lhe markeLplaces. 1he use of medlcal servlces and goods,
especlally prescrlpLlon drugs and physlclan and cllnlcal servlces, among Lhe newly lnsured ls expecLed Lo conLrlbuLe slgnlflcanLly
Lo spendlng lncreases ln Medlcald (12.2) and prlvaLe healLh lnsurance (7.7). CuL-of-pockeL spendlng ls pro[ecLed Lo decllne
1.3 ln 2014 due Lo Lhe new coverage and lower cosL sharlng for Lhose wlLh lmproved coverage. C. Fleming. uS PealLh Spendlng
CrowLh ro[ecLed Lo Average 3.8 ercenL Annually 1hrough 2022, neoltb Affolts 8loq oolloe, SepLember 18, 2013.
21
lorLy-Lhree sLaLes have consLlLuLlonal provlslons relaLlng Lo a balanced budgeL, flve sLaLes have sLaLuLes buL no consLlLuLlonal
provlslons, and [usL Lwo have nelLher. Cf Lhe Lwo LhaL have nelLher: lndlana may carry over annual deflclLs buL cannoL assume
debL, whlch has Lhe effecL of forclng budgeLary dlsclpllne, and vermonL, ln pracLlce, has noL carrled deflclLs from one budgeL year
Lo Lhe nexL. 8esLrlcLlons relaLlng Lo balanced budgeLs may be on Lhe Covernor when he lnLroduces Lhe budgeL (44 sLaLes), on Lhe
LeglslaLure Lo pass a balanced budgeL (41 sLaLes), or on Lhe Covernor when he slgns Lhe budgeL (37 sLaLes). naLlonal AssoclaLlon
of SLaLe Budget Officers, 8oJqet ltocesses lo tbe 5totes, Summer 2008.
"#$%&' =) 0'/#-1#/ 29:'3/#.%&'6 16 *'&-'3. +7 ><*

age: 11
surpluses nearly equaled Lhe aggregaLed deflclLs. 1he second excepLlon ls a brlef perlod from ll?
1998 Lhrough ll? 2001 when Lhe federal governmenL ran surpluses.
AlLhough Lhere ls dlsagreemenL among economlsLs on Lhe
effecLlveness of deflclL spendlng Lo sLlmulaLe Lhe economy
durlng recesslonary Llmes, economlsLs do seem Lo agree on a
number of oLher prlnclples relaLlng Lo deflclLs and debL.
LconomlsLs, ln general, are noL agalnsL federal deflclLs or Lhe
naLlonal governmenL assumlng debL, provlded (1) Lhose
deflclLs do noL become Lhe norm and (2) Lhe magnlLude of Lhe debL remalns manageable. 1hey
usually descrlbe Lhelr concerns ln Lerms of sLrucLural deflclLs, LhaL ls, when Lhere ls conslsLenL deflclL
spendlng on an annual basls durlng good economlc Llmes and bad. 1hey are noL alarmed lf Lhe
federal governmenL carrles debL, buL Lhey become concerned when LhaL debL becomes so large
relaLlve Lo Lhe economy LhaL lL beglns Lo resLrlcL flscal flexlblllLy and causes unwelcomed economlc
consequences.
lor example, mosL people can carry a debL
load. 1hey can afford Lo borrow money Lo
buy a house and a car as long as Lhey have
adequaLe lncome Lo make loan paymenLs.
1hey can spend more ln a year Lhan Lhey
make, provlded Lhey manage Lhelr flnances
over Lhelr llfeLlme and make more money
Lhan Lhey spend ln oLher years. 1he federal
governmenL has a greaLer ablllLy Lo carry
debL and run deflclLs for aL leasL Lwo
lmporLanL reasons. llrsL, lL has no expecLed
llfespan when all debL musL be repald, LhaL
ls, when a person dles. Second, lL has a
number of Lools avallable Lo lL Lo maneuver
flnanclally LhaL are noL avallable Lo
lndlvlduals, such as moneLlzlng debL. CovernmenLs, however, can sLlll overexLend Lhemselves, and
Lhey cerLalnly do.
Cn Lhe flrsL polnL of noL allowlng deflclLs Lo become Lhe norm, lL ls commonly accepLed LhaL Lhe
federal governmenL has a sLrucLural deflclL problem. Cver Lhe lasL flfLy years, Lhe federal
governmenL ran deflclLs nlneLy percenL of Lhe Llme, durlng good economlc Llmes and bad. ln lnflaLlon
ad[usLed dollars, Lhe slx of Lhe Len largesL federal deflclLs slnce 1940 lnclude ll?s 2008 Lhrough 2013,
and flve of Lhose years hold Lhe Lop flve spoLs. As shown on Lhe lefL half of Lhe Lable ln I|gure 4, Lhe
"#$%&' ?) @+: (A B1&$'6. "'/'&14 <'7#-#.6 C13D'/ #3 @E+ F1G6
LconomlsLs, ln general, are noL
agalnsL federal deflclLs provlded
(1) Lhose deflclLs do noL become
Lhe norm and (2) Lhe magnlLude
of Lhe debL remalns manageable.
.
kank II
Inf|at|on Ad[usted
8||||on Do||ars
8ase ear 2013
kank II
ercent of
GD
1 2009 -1,317 1 1943 -30.3
2 2010 -1,373 2 1944 -22.7
3 2011 -1,331 3 1943 -21.3
4 2012 -1,104 4 1942 -14.2
3 2013 -680 3 2009 -10.1
6 1943 -632 6 2010 -9.0
7 1943 -623 7 2011 -8.7
8 1944 -396 8 1946 -7.2
9 2004 -309 9 2012 -7.0
10 2008 -494 10 1983 -6.0
1op 10 Largest Iedera| Def|c|ts S|nce II 1940

age: 12
largesL federal budgeL ever was ll? 2009, whlch was -$1.3
Lrllllon when ad[usLed for lnflaLlon ln 2013 dollars.
22
LconomlsLs
generally belleve, however, LhaL comparlng magnlLudes of
lnflaLlon-ad[usLed deflclLs over Llme may be mlsleadlng because
lL does noL accounL for Lhe growLh of Lhe economy. 1herefore,
Lhey llke Lo compare deflclLs Lo Lhe Cross uomesLlc roducL
(Cu). As shown on Lhe rlghL half of Lhe Lable ln llgure 4, recenL deflclLs are sLlll enormously large.
1he Lop four years wlLh Lhe largesL deflclLs were durlng Lrylng Llmes of World War ll: 1942 Lhrough
1943. 1he nexL Lhree years, however, are 2009, 2010, and 2011.
Cn Lhe second polnL, relaLlng Lo havlng a naLlonal debL LhaL ls manageable, economlsLs llke Lo
compare LoLal naLlonal debL Lo Cu. AgalnsL Lhls meLrlc, Lhe unlLed SLaLes does noL do well aL all.
lor Lhe second quarLer of 2013, Lhe debL-Lo-Cu raLlo was 100.6. llve years ago, Lhe debL-Lo-Cu
raLlo was only 64.8. 1hls calculaLlon uses boLh debL held by Lhe publlc and by Lhe governmenL
lLself, whlch ls known as lnLra-governmenLal debL. 1he laLLer debL conslsLs of Lrue obllgaLlons held
by varlous governmenL agencles, lncludlng Lhe LrusL funds of Soclal SecurlLy and Medlcare.
A comparlson of Lhe unlLed SLaLes Lo oLher counLrles also
lllusLraLes Lhe polnL. lf Lhe unlLed SLaLes were a member of Lhe
Luropean unlon, lL would have Lhe slxLh worsL debL-Lo-Cu raLlo
afLer Creece, lLaly, orLugal,
lreland, and 8elglum, as
lndlcaLed ln Lhe Lable ln
I|gure S whlch compares
Lhe second quarLer of 2013,
Lhe mosL recenL daLa
avallable.
23
noLe on Lhe llsL
LhaL Lhe counLrles closesL Lo Lhe u.S. are counLrles sLruggllng wlLh
serlous economlc problems.
1he hlsLory of Congresslonal acLlons Lo solve Lhe conLlnual deflclL
challenges, whlch have been mosLly unsuccessful, ls long and wlll noL be covered here. Powever, lL

22
uaLa here and ln Lhe charL come from Lhree sources: u.S. Cfflce of ManagemenL and 8udgeL, llscol eot 2014 nlstotlcol 1obles,
8oJqet of tbe u.5. Covetomeot, 1able 1.3, Congresslonal 8udgeL Cfflce, Mootbly 8oJqet kevlew5ommoty fot llscol eot 201J,
november 7, 2013, and Cross uomesLlc roducL daLa from Lhe u.S. 8ureau of Lconomlc Analysls. All values were converLed Lo
base ll? 2013 uslng Cu prlce deflaLors.
23
LuroSLaL, Luropean unlon, Luxembourg, Euro area and EU28 government debt up to 93.4%and 86.8% of GDP, oto5tot News
keleose, 133/2013, CcLober 23, 2013. u.S. uebL calculaLed uslng hLLp://www.LreasurydlrecL.gov/ webslLe of Lhe u.S. ueparLmenL
of 1reasury. Accessed uecember 10, 2013. Cu daLa from u.S. 8ureau of Lconomlc Analysls.
"#$%&' H) I+5:1&' JK <'L.M ><*
C1.#+ .+ 2J I+%3.&#'6

kank Country
1 Greece 169.1
2 Italy 133.3
3 Portugal 131.3
4 Ireland 123.7
3 Belgium 103.0
Un|ted States 100.6
6 Cyprus 98.3
7 France 93.3
8 Spain 92.3
9 United Kingdom 89.6
10 Hungary 81.6
Government Debt to GD 2013 2
Compar|ng US to LU Countr|es
lL ls commonly accepLed LhaL
Lhe federal governmenL has a
sLrucLural deflclL problem. Cver
Lhe lasL flfLy years, Lhe federal
governmenL ran deflclLs nlneLy
percenL of Lhe Llme.
lf Lhe unlLed SLaLes were a
member of Lhe Luropean unlon,
lL would have Lhe slxLh worsL
debL-Lo-Cu raLlo afLer Creece,
lLaly, orLugal, lreland, and
8elglum.

age: 13
ls lmporLanL Lo know abouL recenL aLLempLs LhaL may have an lmpacL on fuLure spendlng on
Medlcald.
llrsL proposed by resldenL 8lll CllnLon
24
as parL of hls 1997 budgeL proposal, pet coplto caps would
transform Medicaids financing mechanism by limiting each state to fixed dollar relmbursemenLs for
each reclplenL as opposed Lo Lhe currenL meLhod of paylng for a percenLage share of Lhe cosLs. ln
essence, program spendlng growLh would be llnked Lo enrollmenL, noL Lhe overall cosL of spendlng.
AlLhough pet coplto caps have been uLlllzed ln selecL Medlcald demonsLraLlon pro[ecLs Lo ensure
federal expendlLures do noL surpass a speclfled LoLal, Lhey have never been applled Lo Lhe enLlre
program. Whlle pet coplto caps are Lyplcally proposed Lo save Lhe federal governmenL money, sLaLes
would mosL llkely have Lo make up Lhe dlfference.
23

ulfferenL meLhodologles can be uLlllzed ln deLermlnlng pet coplto caps. Cne meLhod would esLabllsh
a federal relmbursemenL llmlL per each reclplenL, and sLaLes would be responslble for any amounL
spenL over LhaL llmlL. Some meLhods would Lake lnLo accounL Lhe hlsLorlc per-reclplenL Medlcald
spendlng of Lhe sLaLes, esLabllshlng llmlLs on a sLaLe speclflc basls. CLher meLhods would seL up
separaLe caps based on speclflc populaLlon groups.
AlLhough Lhe lmplemenLaLlon of pet coplto caps would provlde sLaLes wlLh sLrlcLer spendlng llmlLs,
Lyplcal proposals have allowed lncreased flexlblllLy Lo avold federal rules around cosL sharlng and
Lhe modlflcaLlon of beneflLs. llexlblllLy wlLh federal ellglblllLy rules however, would mosL llkely noL
be granLed, Lhus assurlng Lhe conLlnuaLlon of hlsLorlc caseload growLh and a slgnlflcanL loss of
federal dollars Lo sLaLes.
26

Congressman 8lll Cassldy from Loulslana provldes a recenL example of how Lhls cosL savlng lnlLlaLlve
conLlnues Lo resurface when ln 2012 he proposed Lo equallze Medlcald spendlng across all sLaLes
wlLh a pet coplto cap LhaL varled by Medlcald caLegory.
27
Pls proposal called for pet coplto caps LhaL
dlffered for ellglblllLy groups, such as chlldren, adulLs, Lhe bllnd and lndlvlduals wlLh dlsablllLles, and
elderly lndlvlduals recelvlng long-Lerm care servlces, based on Lhe medlan cosL of care.
28
aymenLs

24
When Lhe CC-conLrolled Congress passed a Medlcald block granL blll ln Lhe laLe 1990s, resldenL CllnLon veLoed lL and ln
response proposed hls pet coplto cap method as a compromise. Under the Presidents proposal, the caps would be calculaLed for
spendlng on speclflc ellglblllLy groups, such as lndlvlduals wlLh dlsablllLles, non-dlsabled adulLs, chlldren, and Lhe elderly.
23
Ldwln ark and MaLL 8roaddus, Medicaid Per Capita Cap Would Shift Costs to States and Place Low-lncome 8eneflclarles aL 8lsk,
CenLer fot 8oJqet ooJ lollcy ltlotltles, CcLober 4, 2012.
26
Lven Lhough per caplLa caps normally lmpose a llmlLaLlon on sLaLe flexlblllLy Lo make slgnlflcanL changes Lo Lhe sysLem, lL ls
posslble (alLhough noL probable) LhaL Congress could amend federal law Lo allow modlflcaLlons Lo enrollmenL and ellglblllLy.
27
Bill Cassidy, Cassidy Eyes Per Capita Caps For States As Part Of Medicaid Reform Proposal, loslJe neoltb lollcy, March 6, 2012,
accessed aL: hLLp://lnsldehealLhpollcy.com/lnslde-PealLh-Ceneral/ubllc-ConLenL/cassldy-eyes-per-caplLa-caps-for-sLaLes-as-
parL-of-medlcald-reform-proposal/menu-ld-869.hLml
28
CrlLlcs of per caplLa caps have argued LhaL Lhey do noL Lake lnLo conslderaLlon unanLlclpaLed healLh care cosL growLh or fuLure
demographlc changes.

age: 14
under hls proposal would be rlsk ad[usLed for Lhe populaLlon as well as down Lo Lhe reclplenL.
29

More recenLly, on May 1, 2013, SenaLor Crrln PaLch (8-uLah) and 8epresenLaLlve lred upLon (8-
Mich.) made public a plan for Making Medicaid Work. One of their blueprints key proposals was
Lo lmplemenL per caplLa caps.
30

PlsLorlcally, Llmes of federal flnanclal crlses have been Lhe maln raLlonale for lmposlng pet coplto
caps. CerLaln pollcymakers, however, belleve LhaL ln addlLlon Lo savlng money, Lhey would lmprove
care. AlLhough no pet coplto cap proposal has been lmplemenLed across Lhe enLlre program Lo daLe,
Lhe growlng federal budgeL deflclLas well as a fundamenLal bellef by cerLaln pollcymakers LhaL
caps lncenLlvlze lmproved ouLcomesmakes cerLaln LhaL pet coplto caps wlll conLlnue Lo be offered
as a soluLlon Lo Lhe currenL flscal challenges faced by Lhe federal governmenL.
ln 2011, debaLe over ralslng Lhe debL celllng of
Lhe federal governmenL led Lo a compromlse. ln
exchange for ralslng Lhe celllng, Congress creaLed
a !olnL SelecL CommlLLee on ueflclL 8educLlon
wlLh Lhe enacLmenL of Lhe 8udgeL ConLrol AcL of
2011. 1he SelecL CommlLLee was charged wlLh developlng and proposlng a blparLlsan budgeL Lo
reduce Lhe budgeL by $1.3 Lrllllon over Len years. lf Lhe SelecL CommlLLee falled by !anuary 13, 2012,
Lo have leglslaLlon enacLed LhaL would achleve a $1.2 Lrllllon deflclL reducLlon, Lhe AcL Lrlggered
auLomaLlc reducLlons ln defense and oLher dlscreLlonary spendlng spread evenly over ll?s 2013
through 2021, also known as sepoesttotloo. The Act exempted Medicaid from the automatic
spendlng cuLs. 1he SelecL CommlLLee falled, Lrlggerlng Lhe auLomaLlc spendlng cuLs.
31
WlLh Lhe help
of sepoesttotloo, Lhe currenL federal deflclL ln ll? 2013 was reduced Lo $680 bllllon, whlch was Lhe
flrsL Llme lL fell below $1 Lrllllon slnce ll? 2008. Powever, ll? 2013 ls sLlll Lhe flfLh largesL budgeL
deflclL ln lnflaLlon-ad[usLed dollars slnce 1940, and Lhe 18
Lh
ln Lerms of a percenL of Cu.
AlLhough Medlcald was exempLed ln Lhe 2011 AcL, Lhere ls no guaranLee LhaL Congress wlll be able
Lo conLlnue exempLlng Medlcald from budgeL cuLs ln Lhe fuLure. Medlcald compeLes agalnsL oLher
prlorlLles also consldered Lo be very lmporLanL, lncludlng Medlcare, federal penslons, veLeran
beneflLs, food asslsLance, and houslng. AddlLlonally, Lhe conLlnual growLh ln Medlcald brlngs
aLLenLlon Lo Lhe lssue of growLh.

29
lJem. Also, Congressman Cassldy clalmed LhaL under hls proposal Lhe money would follow Lhe paLlenL and produce beLLer
ouLcomes.
30
SenaLors lred upLon and Crln PaLch, Making Medicaid Work: Protect the Vulnerable, Offer Individuallzed Care, and 8educe
Costs, May 1, 2013, accessed aL:
hLLp://energycommerce.house.gov/slLes/republlcans.energycommerce.house.gov/flles/analysls/20130301Medlcald.pdf
31
1he Amerlcan 1axpayer 8ellef AcL of 2012, whlch was passed on !anuary 1, 2013, delayed sequesLraLlon from !anuary 2, 2013,
unLll March 1, 2013.
AlLhough Medlcald was exempLed ln Lhe 2011
ueflclL 8educLlon plans, Lhere ls no guaranLee
LhaL Congress wlll be able Lo exempL Medlcald
from budgeL cuLs ln Lhe fuLure.

age: 13
I|gure 6
32
for example, llsLs Medlcald as havlng Lhe hlghesL percenLage lncrease ln expendlLure
growLh of all ma[or budgeLary caLegorles for boLh ll?s 2012 and 2013. Conslderlng LhaL Lhe naLlonal
debL grew aL 3.4 from uecember 2012 Lo uecember 2013 whlle Cu has only grown 3.3 (or 1.8
lf you ad[usL for lnflaLlon), Lhe naLlonal debL conLlnues Lo grow fasLer Lhan Cu, placlng pressure on
Congress Lo acL on Lhe deflclL problem.
1he numbers alone call aLLenLlon Lo Lhe Medlcald program, and Lhe soluLlon from Lhe polnL of vlew
of Lhe federal governmenL ls obvlous. lederal deflclLs conLlnue Lo mounL, addlng Lo Lhe naLlonal
debL aL a fasLer raLe Lhan Cu growLh, and Medlcald ls Lhe fasLesL growlng budgeL caLegory. !usL
recenLly, Lhe Congresslonal 8udgeL Cfflce suggesLed an opLlon Lo lmpose a cap on federal Medlcald
spendlng Lo help brlng Lhe federal deflclL problem under conLrol.

32
Congresslonal 8udgeL Cfflce (C8C), Mootbly 8oJqet kevlew, november 7, 2013.
"#$%&' N) @+.14 O%.41G6 7&+5 "'/'&14 >+P'&35'3. 8A((Q8A(=

age: 16
ln november 2013, Lhe Congresslonal 8udgeL
Cfflce publlshed Lhe reporL Optloos fot keJocloq
tbe ueflclt. 2014 to 202J, and Lhe very flrsL opLlon
llsLed under Lhe caLegory of healLh ls capplng
Medlcald spendlng.
1he report points out that CBO expects federal
Medlcald Lo grow aL a hlgher raLe over Lhe nexL decade, an average of 8 a year. Note that this
forecast is almost two percentage points higher than the forecast by the USDHHSs Office of the
AcLuary covered earller ln Lhls secLlon. 1he quoLe below ls from Lhe C8C reporL.
Lawmakers could make various structural changes to MedicalJ to Jecteose feJetol
speoJloq fot tbe ptoqtom. 1bose cbooqes locloJe teJocloq tbe scope of coveteJ
setvlces, ellmlootloq ellqlblllty coteqotles, tepeolloq tbe MeJlcolJ expoosloo Joe to
start in 2014, lowering the federal governments share of total MedicolJ speoJloq,
ot copploq tbe omooot tbot eocb stote tecelves ftom tbe feJetol qovetomeot to
opetote tbe ptoqtom.
33

1he reporL dlscusses ln greaL lengLh Lhe pros and cons wlLh speclflc recommendaLlons on ways Lo
cuL back on Medlcald spendlng. Cne obvlous way would be Lo reduce lMAs. Clearly, Lhere ls rlsk
LhaL Congress may shlfL more cosLs of Medlcald Lo Lhe sLaLes, and Sect|on VI of Lhls reporL wlll
address LhaL rlsk more fully.
34

lesoect|ve om t|e States
PealLh care and lLs anclllary supporL servlces are the largest items in states budgets, and it is
noLeworLhy LhaL one of Lhe concluslons of Lhe offlclal acLuarlal reporL on Medlcald lnvolves Lhe
budgeLs of Lhe sLaLes:
Despite the amount of time that has passed since the end of the recession, some of
lts effects oo MeJlcolJ stlll temolo. otollmeot ls ptojecteJ to bove qtowo mote
polckly tboo tbe u.5. popolotloo lo 2012, olbelt ot slowet totes tboo lo teceot yeots.
1be expltotloo of tbe tempototy leJetol motcbloq tote locteoses leJ to sobstootlol
locteases in State Medicaid expenditures, but States budget revenues have not kept
poce, tbese coofllctloq tteoJs oppeot to bove beeo o slqolflcoot teosoo fot tbe
telotlvely slow tote of MeJlcolJ expeoJltote qtowtb lo 2012.
33

33
Congresslonal 8udgeL Cfflce, Optloos fot keJocloq tbe ueflclt. 2014 to 202J, november 2013.
34
Especially when one considers that the ACAs Medicaid expansion funding is at 90 Lo 100, lL would be hard pressed for any
Congress or resldenL Lo lncrease fundlng. 1he only way Lo move aL Lhls polnL would be Lo reduce fundlng.
33
2012 Actootlol kepott oo tbe lloooclol Ootlook fot MeJlcolJ, p. 32.
ln november 2013, Lhe Congresslonal 8udgeL
Cfflce 8eporL sLaLes LhaL Medlcald ls expecLed
Lo grow aL an average raLe of 8 over Lhe nexL
decade, nearly 2 percenLage polnLs hlgher
than the USDHHS Actuarial Report.

age: 17
As can be expecLed, Medlcald expendlLures have been a
ma[or concern of Lhe sLaLes. 1he naLlonal AssoclaLlon of
SLaLe 8udgeL Cfflcers (nAS8C) produces perlodlc
lnformaLlon on Lhe flscal slLuaLlon of Lhe sLaLes, and
Medlcald has played a cenLral role ln Lhose publlcaLlons.
1he mosL recenL SLaLe LxpendlLure 8eporL, publlshed ln
november 2013, shows LhaL once agaln Medlcald ls Lhe
largest component of states total budgets, comprising on average 24.5%, i.e., almost one in every
four dollars LhaL a sLaLe spends goes Lo Medlcald. 1he growLh has been sLeady over Llme. ln 1990,
Medlcald surpassed hlgher educaLlon as Lhe second largesL sLaLe program, and ln 2003 lL surpassed
elemenLary and secondary educaLlon (baslc educaLlon) Lo become Lhe largesL program. lor Lhe nexL
several years, baslc educaLlon and Medlcald Lraded places, buL now Medlcald holds a subsLanLlal
lead over baslc educaLlon: 24.3 versus 20.0.
36

I|gure 7 is a chart that compares Maines spending to the national average. Maines spendlng
paLLern preceded Lhe naLlonal paLLern by more Lhan Len years. Medlcald overLook baslc educaLlon
spendlng as a percenLage of Lhe LoLal budgeL ln 1992 for Malne. lor SLaLe llscal ?ear (Sl?) 2012-13,
Medlcald spendlng was 32.2 of Lhe budgeL, nearly double Lhe 16.6 for baslc educaLlon.

36
1he growLh of Lhe Medlcald program and lLs crowdlng ouL of oLher lmporLanL prlorlLles has been a ma[or concern for mosL
governors, democraL and republlcan. As recenLly as 2012, MonLana Covernor 8rlan SchwelLzer, a uemocraL, Lold Lhe WashlngLon
osL LhaL, "unllke Lhe federal governmenL, MonLana can'L [usL prlnL money. We have a budgeL surplus, and we're golng Lo keep lL
LhaL way." See n.C. Alzenman and karen 1umulLy, uemocraLs Share Concerns over Medlcald Lxpanslon, wosbloqtoo lost, !uly
13, 2012, p. A3.
Accordlng Lo Lhe naLlonal AssoclaLlon
of SLaLe 8udgeL Cfflcers (nAS8C), ln
2003 Medlcald surpassed elemenLary
and secondary educaLlon (baslc
educaLlon) Lo become Lhe largesL
sLaLe budgeLary rogram.
"#$%&' R) I+5:1&#3$ 01#3' .+ .S' T1.#+314 UP'&1$' 7+& 01,+& 29:'3/#.%&'6

age: 18
uslng esLlmaLed nAS8C daLa for Sl? 2013, Malne ranks low ln baslc educaLlon expendlLures as a
percenLage of Lhe LoLal sLaLe budgeL and very hlgh ln Medlcald expendlLures as a percenLage of Lhe
LoLal sLaLe budgeL compared Lo oLher sLaLes. (See I|gure 8.)
37

I|gure 8 also shows Lhe Lop flve sLaLes for each of
Lhese caLegorles and provldes Lhe ranklngs for
Malne, new Pampshlre, and Lhe sLaLe average.
vermonL spends Lhe mosL of any sLaLe on baslc
educaLlon aL 32.3, followed by lndlana aL
31.3. new Pampshlre ranks 13
Lh
aL 23.3. 1he
sLaLe average ls 19.4. Malne ranks 31
sL
aL
16.6. lor Medlcald, Malne has Lhe Lhlrd hlghesL
expendlLure aL 32.2, afLer Mlssourl and
ennsylvanla. new Pampshlre ls 13
Lh
aL 23.6
and Lhe sLaLe average ls 22.8.
1he crowdlng ouL of sLaLe spendlng for k-12 educaLlon, boLh naLlonally and sLaLe-by-sLaLe, may help
explaln why Lhere have been only marglnal galns ln educaLlonal ouLcomes slnce Lhe 1970s, when
Lhe upward Lrend ln hlgh-school graduaLlon raLes of Lhe 20Lh cenLury a paLLern LhaL had helped
Lo fuel worker producLlvlLy and economlc growLh came Lo a halL.
AlLhough Malne, llke oLher sLaLes, has experlenced an lncrease ln
hlgh-school graduaLlon raLes slnce 2003, Lhe recenL upLlck
represenLs mosLly a reLurn Lo Lhe basellne of 40 years ago. AL Lhe
same Llme, Malne has seen slgnlflcanL decllnes ln Lhe mean SA1
scores, boLh readlng and maLh, of college-bound hlgh-school
senlors, slnce Lhe mld-1990s, accordlng Lo daLa from Lhe naLlonal
AssessmenL of LducaLlonal rogress.
38

ubllc safeLy and correcLlons are Lwo oLher prlorlLy areas where sLaLes are sLruggllng Lo malnLaln
fundlng. uecreased budgeLs for pollce can resulL ln less crlmes belng solved, lf noL hlgher crlme
raLes, due Lo reducLlons ln manpower and oLher resources. uecreased budgeLs for correcLlons have
noL only resulLed ln reduced sLafflng, ralslng safeLy concerns for correcLlonal offlcers, buL have also
forced some sLaLes Lo release prlsoners early. lor example, Lhe u.S. Supreme CourL ruled ln May
2011 LhaL Callfornla had Lo reduce lLs prlson populaLlon by 32,000 over Lwo years because lLs
overcrowdlng problem vlolaLed Lhe LlghLh AmendmenL Lo Lhe u.S. ConsLlLuLlon.
39
?eL puLLlng

37
naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers, 5tote xpeoJltote kepott. xomloloq llscol 2011201J 5tote 5peoJloq. 2013.
38
naLlonal CenLer for LducaLlonal SLaLlsLlcs, ulqest of Jocotloool 5totlstlcs, 1able 174, accessed aL:
hLLp://nces.ed.gov/programs/dlgesL/d12/Lables/dL12_174.asp.
39
8rown, Covernor of Callfornla, et ol. v. lloto et ol.
"#$%&' V) K.1.' C13D6 7+& K:'3/#3$ +3 ;16#- 2/%-1.#+3 M
0'/#-1#/
State and kank State and kank
1. vermonL 33 1. Mlssourl 36
2. lndlana 31 2. ennsylvanla 34
3. Ceorgla 31 3. Ma|ne 32
4. MlnnesoLa 27 4. Arlzona 32
3. 1exas 27 3. lndlana 32
13. New nampsh|re 23 1S. New nampsh|re 26
K.1.' 1P'&1$' (W K.1.' 1P'&1$' 8=
31. Ma|ne 17
Lducat|on
SI 2013 ercentage of 1ota| State 8udget
Med|ca|d
Malne ranks low ln baslc
educaLlon expendlLures as
a percenLage of Lhe LoLal
sLaLe budgeL and very hlgh
ln Medlcald expendlLures
as a percenLage of Lhe
LoLal sLaLe budgeL
compared Lo oLher sLaLes.


age: 19
vlolenL offenders back on Lhe sLreeL poses clear dangers Lo Lhe publlc. Whlle Malne has experlenced
a decline in rates of index crime, meaning the most serious and commonly reported crimes, it has
noneLheless experlenced sharp [umps ln raLes of rape, domesLlc vlolence, and especlally drug-
relaLed crlme. Moreover, offender recldlvlsm raLes are rlslng. Accordlng Lo Lhe Malne SLaLlsLlcal
Analysis Center, a function of the University of Southern Maines Muskie School of Public Service,
arresLs for drug-abuse vlolaLlons have lncreased dramaLlcally ln Lhe pasL 23 years. As a percenLage
of all arresLs ln Malne, drug arresLs have [umped from more Lhan 4 ln 1986 Lo nearly 11 ln 2010.
Less lunos o vu|neab|e loou|at|ons
revlous caseload expanslons and burgeonlng cosLs have also placed a sLraln on Lhe capaclLy of Lhe
Medlcald programs Lo serve Lhe mosL vulnerable populaLlons, as parLlally evldenced by walLlng llsLs.
AL a Llme when a number of sLaLes are movlng lncreased numbers of healLhy adulLs of worklng age
onLo Lhe Medlcald rolls, a number of sLaLe Medlcald programs possess walLlng llsLs for currenL
programs servlng Lhe needlesL populaLlon groups. 1hese servlces, provlded malnly Lhrough SecLlon
1913(c) home and communlLy based (PC8S) walvers,
40
generally serve vulnerable populaLlons LhaL
requlre more lnLense servlces and supporLs, such as lndlvlduals wlLh lnLellecLual dlsablllLles or Lhe
elderly, Lo avold lnsLlLuLlonal care.
41
A 2011 kalser loundaLlon reporL showed Lhe walL llsL for
Malnes 1913(c) walver programs Lo be almosL Lwo Lhousand whlle oLher new Lngland SLaLes had a
lower number of clLlzens awalLlng servlces. Some oLher sLaLes had no walL llsLs aL Lhe Llme of Lhe
sLudy.
42
ennsylvanla was Lhe closesL sLaLe geographlcally wlLh a walL llsL LhaL exceeded Malne aL
Lhe Llme of Lhe sLudy, and Lhere were LwenLy-Lwo sLaLes ln Lhe reporL wlLh walL llsL populaLlons less
Lhan LhaL of Malne.
43
8y elecLlng Lo change Lhe purpose of Medlcald from a program Lo serve
vulnerable populations to one that serves everyone below a fixed income level, expanding states
seem Lo be glvlng llLLle conslderaLlon of how Lo handle Lhe populaLlons LhaL have had Lo endure

40
1he 1913(c) walvers are one of many opLlons avallable Lo sLaLes Lo allow Lhe provlslon of long Lerm care servlces ln home and
communlLy based seLLlngs under Lhe Medlcald rogram. SLaLes can offer a varleLy of servlces under an PC8S walver program.
rograms can provlde a comblnaLlon of sLandard medlcal servlces and non-medlcal servlces. SLandard servlces lnclude buL are
noL llmlLed Lo: case managemenL (l.e., supporLs and servlce coordlnaLlon), homemaker, home healLh alde, personal care, adulL
day healLh servlces, hablllLaLlon (boLh day and resldenLlal), and resplLe care. States can also propose other types of services
LhaL may asslsL ln dlverLlng and/or LranslLlonlng lndlvlduals from lnsLlLuLlonal seLLlngs lnLo Lhelr homes and communlLy. See
www.Medlcald.gov.
41
Medlcald ls a llfellne for mosL people wlLh slgnlflcanL dlsablllLles who have greaLer medlcal needs and ofLen requlre asslsLance
wlLh acLlvlLles of dally llvlng LhroughouL Lhelr llfeLlmes, such as geLLlng dressed, Laklng medlcaLlon, preparlng meals, and managlng
money. Medlcald ls overwhelmlngly Lhe largesL fundlng source of boLh acuLe healLh care and long Lerm servlces and supporLs
slnce people wlLh dlsablllLles who are covered by Medlcald generally do noL have access Lo employer based or oLher prlvaLe
coverage.
42
Accordlng Lo Lhe kalser 2011 SLaLe PealLh lacLs on WalLlng LlsLs, due Lo Lhe llmlLed number of PC8S sloLs ln sLaLes, Lhere are over
300,000 people on walLlng llsLs for servlces, over 300,000 of whom are dlsabled. 1he walL can be as long as 8-10 years. 1hls crlsls
resulLs ln unnecessary, unwanLed and cosLly lnsLlLuLlonal care, famlly members belng forced Lo qulL [obs or Lake on second [obs
Lo help care for Lhelr loved one, and famllles havlng Lo leave Lhelr loved ones unaLLended or ln Lhe care of unquallfled persons.
43
ln Sl? 2013, Lhe Leage AdmlnlsLraLlon commlLLed $3.3 mllllon Lo reduce Lhe walLlng llsL for Lhe lnLellecLually dlsabled. Lven wlLh
LhaL commlLmenL, Malne sLlll has 1,328 lndlvlduals walLlng for servlces.

age: 20
walLlng llsLs. 1hese populaLlons represenL, ln mosL cases, lndlvlduals who cannoL be easlly served
Lhrough commerclal healLh plans, unllke Lhe expanded populaLlon.
lnaoequate layment to lov|oes
ln addlLlon Lo Lhe lssue of walL llsLs, many sLaLes are concerned abouL Lhelr ablllLy Lo malnLaln
exlsLlng servlce levels or Lo provlde for Lhose enLerlng Lhe Medlcald program. Malne llke all sLaLes,
sLruggles Lo pay physlclans adequaLely. lor every dollar LhaL prlvaLe lnsurers pay a physlclan,
MalneCare pays 42 cenLs on Lhe dollar, Lhe second lowesL ln new Lngland. (See I|gure 9.)
44

ln an aLLempL Lo address some of Lhese lssues, Lhe ACA requlred cerLaln changes Lo provlder raLe
sLrucLures. 1he ACA mandaLed LhaL Medlcald relmbursemenL raLes Lo physlclans ln famlly Medlcald,
general lnLernal medlclne, pedlaLrlc medlclne, and subspeclalLles
who provlde prlmary care servlces be ralsed Lo 100 of Medlcare
raLes buL only Lhrough calendar year 2014. CLher parLs of Lhe ACA
provlde lncreased fundlng Lo safeLy-neL provlders LhaL serve low-
lncome lndlvlduals and famllles. 1hls occurred aL a Llme when mosL
sLaLes were sLruggllng wlLh revenue slumps due Lo Lhe recesslon
and because of budgeL deflclencles were cuLLlng relmbursemenL
raLes, noL lncreaslng Lhem.

44 Avlk 8oy, Pow uo 8lue SLaLes Lxpand Medlcald? 8y aylng uocLors, lotbes, accessed uecember 1, 2013, aL:
hLLp://www.forbes.com/slLes/LheapoLhecary/2012/07/23/how-do-blue-sLaLes-expand-medlcald-by-paylng-docLors-less/.
"#$%&' W) I'3.6 +3 .S' <+441& 0'/#-1#/ *1G6 C'41.#P' .+ *&#P1.' X36%&'&6 LG K.1.'
Malne sLruggles Lo pay
physlclans adequaLely. lor
every dollar LhaL prlvaLe
lnsurers pay a physlclan,
MalneCare pays 42 cenLs
on Lhe dollar, Lhe second
lowesL ln new Lngland.

age: 21
uesplLe Lhese lncreases ln raLes, many reporLs, lncludlng one from Lhe nonparLlsan economlc and
soclal research group urban lnsLlLuLe,
43
noLed LhaL mosL sLaLes belleved LhaL Lhe Lemporary raLe
lncrease would have llLLle effecL on aLLracLlng new physlclans wllllng Lo accepL new Medlcald
paLlenLs buL belleved lL would help malnLaln provlder parLlclpaLlon ln Lhe shorL Lerm.
1he same reporL noLed LhaL Lhe raLe lncreases are esLlmaLed Lo lncrease provlder parLlclpaLlon by
11, whlch would noL be sufflclenL enough Lo cover Lhe currenL exlsLlng shorLage much less Lhe
addlLlonal caseloads as a resulL of mandaLory lncreases.
46
PealLhockeL, lnc., released a survey LhaL
was conducLed on more Lhan 1 mllllon healLh care professlons, noLlng only 43 were llsLed as
accepLlng Medlcald. ConsequenLly, whlle 73 of Malne docLors may be wllllng Lo accepL new
Medlcald paLlenLs, anoLher 10 are expecLed Lo drop Medlcald paLlenLs ln Lhe comlng monLhs.
47

1he lack of a sufflclenL number of provlders ls also affecLed
by pollcy and regulaLlon. As wlLh many large governmenL
agencies, Medicaids continuously growing bureaucratic
and regulaLory sLrucLure has Lyplcally become dlfflculL Lo
manage and ouLmoded.
48
SLaLes LhaL wanL Lo deflne goals
dlfferenLly from federal sLandards or Lry lnnovaLlve
approaches are requlred Lo seek federal approval ln Lhe
form of walvers. 1he subsequenL resulL for many sLaLes
has become a cumbersome seL of rules and dlfferenL
servlces (and servlce deflnlLlons) LhaL do noL comporL or LranslLlon across Lhe many operaLlng
walvers. 1hey can also be dlfflculL Lo navlgaLe, manage, and
monlLor, and mosL of Lhe Llme have very llLLle Lo do wlLh
lmproved overall healLh ouLcomes. unforLunaLely, because
Lhe admlnlsLraLlon and operaLlon of Medlcald has become so
overly burdensome and complex, Lhe very people who Lhe
sysLem ls supposed Lo serve can become harmed ln Lhe
process by recelvlng lnadequaLe or poor quallLy care.
AddlLlonal evldence of Lhe cumbersome sLrucLure ls
demonsLraLed by Lhe years some sLaLes walL Lo obLaln walvers
and Lhe lnablllLy of Lhe currenL federal admlnlsLraLlon Lo lmplemenL several ma[or pollcy measures

43
urban lnstitute, Pard CuesLlon on Access Lo PealLhcare Wlll we have enough uocLors?
hLLp://www.urban.org/lssues/hardquesLlons/accessLohealLhcare.cfm, accessed uecember 10, 2013.
46
HealthPocket, With Expansion Looming, Less than Half of hyslclans AccepL Medlcald,
hLLp://www.healLhpockeL.com/healLhcare-research/lnfosLaL/less-Lhan-half-of-physlclans-accepL-medlcald, accessed uecember
10, 2013.
47
PealLh Affalrs, AugusL 2012, vol. 31, no. 8, pp. 1673-1679.
48
President Obama recently stated in an MSNBC interview with Chris Matthews that we have these big agencies, some of whlch
are ouLdaLed, some of whlch are not designed properly, accessed aL: hLLp://dyn.pollLlco.com/prlnLsLory.cfm?uuld=048u0321-
3luL-4793-9939-78L8AAC81C67.
As wlLh many large governmenL
agencies, Medicaids continuously
growlng bureaucraLlc and
regulaLory sLrucLure has Lyplcally
become cumbersome and archalc
wlLh a myrlad of dlsparaLe rules and
regulaLlons across populaLlons.
lederal regulaLlons favor cosLly
lnsLlLuLlonal care when less
expenslve communlLy and home-
based opLlons would serve
reclplenLs more approprlaLely.
Close to 60% of Medicaids long
Lerm care fundlng goes Lo
lnsLlLuLlonal care.

age: 22
of Lhe ACA ln !anuary 2013, llke lssulng guldance on how sLaLes were Lo lmplemenL a new coverage
option called the basic health program aimed at helping low and middle income families who did
noL quallfy for Medlcald galn coverage.
Moe Aoooo|ate Cae Sett|ng leeoeo: lnst|tut|ona| u|as o lome ano Commun|ty
uaseo Sev|ces (lCuS)
lederal Medlcald regulaLlons sLlll favor cosLly lnsLlLuLlonal care for lndlvlduals wlLh dlsablllLles and
Lhe elderly when less expenslve communlLy and home-based opLlons would serve Lhese lndlvlduals
more approprlaLely. CurrenLly, close Lo 60% of Medicaids long Lerm care fundlng goes Lo
lnsLlLuLlonal care.
49
1hls blas Lowards lnsLlLuLlonal care ls due Lo Lhe facL LhaL nurslng home servlces
are mandaLory for sLaLes, whlle PC8S are opLlonal. SLaLes currenLly have Lwo maln opLlons Lo fund
PC8S Lhrough Medlcald Lhe PC8S walver (SecLlon 1913(c)) or Lhe PC8S sLaLe plan opLlon (SecLlon
1913(l)). 1he 1913(c) walver ls only avallable Lo lndlvlduals who quallfy for an lostltotloool level of
cote. under Lhls walver, sLaLes can cap Lhe number of ellglble people, malnLaln walLlng llsLs, and
llmlL servlces Lo cerLaln geographlc areas. AddlLlonally, sLaLes musL apply for renewal of Lhe walver
from Medlcald, whlch ls a burdensome and lengLhy process. 1he 1913(l) sLaLe plan opLlon, on Lhe
oLher hand, allows sLaLes Lo have ellglblllLy LhaL ls below Lhe lnsLlLuLlonal level of care before people
need nurslng home care.
30

Malne offers a number of dlfferenL Medlcald servlces for PC8S. ln addlLlon Lo mandaLory and
opLlonal Medlcald SLaLe lan servlces, Lhere are currenLly flve approved home and communlLy based
walvers LhaL serve elders, adulLs wlLh physlcal and lnLellecLual dlsablllLles, and chlldren, lncludlng
one recenLly recelved approved speclflc Lo adulLs who have experlenced Cerebral alsy, Selzure
ulsorders, or oLher condlLlons durlng Lhelr flrsL 21 years of llfe causlng slgnlflcanL dlsablllLles
(referred to as Other Related Conditions). The Maine Department of Health and Human Services
(MuPPS) ls also explorlng a walver Lo serve lndlvlduals wlLh acqulred braln ln[ury ln fuLure years.
31

lurLher, MuPPS LogeLher wlLh leglslaLlve supporL ls ln Lhe mldsL of aLLempLlng Lo remedlaLe and
slmpllfy Lhe complex operaLlonal long Lerm care sysLem LhaL has been lnsLlLuLlonallzed ln Lhe
deparLmenL over Lhe pasL 30 years or more. AlLhough Lhe MuPPS has begun Lo flx Lhe sysLem and
wlLh lL properly allocaLe funds across populaLlons Lo begln addresslng Lhe lmpendlng aglng of Lhe
populaLlon and Lhe complexlLles LhaL go along wlLh lL, ma[or sLrucLural reforms are sLlll necessary Lo

49
SLrldes have been made over Lhe pasL 13 years Lo change Lhe lnsLlLuLlonal blas ln Medlcald, however, Lhe labyrlnLh of burdensome
federal rules and regulaLlons and Lhe Ledlous walver and sLaLe plan amendmenL process have made Lhe underLaklng of balanclng
Lhe sysLem and lmplemenLlng approprlaLe care seLLlngs lnconvenlenL and admlnlsLraLlvely burdensome for sLaLes.
30
1he Affordable Care AcL does provlde a new sLaLe plan opLlon Lo provlde home and communlLy-based servlces ln Medlcald
SecLlon, 1913(k). Also, as of Aprll 2010, Lhe 1913(l) sLaLe plan opLlon no longer allows sLaLes Lo cap Lhe number of ellglble people,
keep walLlng llsLs, and llmlL servlces Lo cerLaln geographlc areas. 1hey may LargeL servlces Lo cerLaln populaLlon groups.
31
See MuPPSs 8alanclng lncenLlve aymenL rogram AppllcaLlon, May 2013, accessed aL: hLLp://www.medlcald.gov/Medlcald-
CPl-rogram-lnformaLlon/8y-1oplcs/Long-1erm-Servlces-and-SupporL/8alanclng/uownloads/Malne-8l.pdf.

age: 23
Lhe currenL enLerprlse Lo creaLe flscal sLablllLy and
susLalnablllLy so LhaL Lhe currenL and fuLure needs of
people wlLh chronlc and co-occurrlng long Lerm supporL
and servlce needs are meL wlLh quallLy and dlgnlLy.
Pavlng recenLly recelved a granL called Lhe 8alanclng
lncenLlves rogram CranL (8l), Malne underLook a ma[or
lnlLlaLlve LhaL lncludes Lhe followlng:
Worklng wlLh communlLy parLners and sLakeholders ln a collaboraLlve fashlon Lo achleve Lhe
goals of lncreaslng home and communlLy based supporLs,
8ulldlng upon Lhe supporLs LhaL Malne currenLly has ln place Lo creaLe a no Wrong
uoor/Slngle LnLry olnL sysLem,
ueveloplng sLaLewlde core sLandardlzed assessmenLs, and
CreaLlng a confllcL-free case managemenL sysLem.
1hls granL wlll complemenL oLher ongolng lnlLlaLlves ln Malne almed aL sysLem reform and
rebalanclng long-Lerm servlces and supporLs (L1SS) Lowards communlLy llvlng.
uesplLe Lhe lncluslon of Lhese and oLher lncremenLal changes Lo MalneCare over Lhe years and Lhe
currenL work of Lhe Leage AdmlnlsLraLlon Lo bolsLer home and communlLy based servlces and
balance Lhe sysLem, Lhe blas Loward lnsLlLuLlonal care remalns. 8ecause MDHHS operational
resources are severely llmlLed, lL would seem proper LhaL MalneCare conLlnue Lo focus on creaLlng
and lmplemenLlng sLrucLural reforms, whlch are deslgned Lo offer more approprlaLe care seLLlngs
for elderly and vulnerable populaLlons and whlch wlll lmprove Lhe quallLy of care for all reclplenLs
Lhrough currenL and fuLure federal parLnershlps llke 8l, wlLhouL havlng Lhe addlLlonal burden of
Laklng on new populaLlons vla Lhe ACA aL Lhe currenL Llme.
loo lea|t| Cutcomes
More dlsLurblng and perhaps relaLed Lo problems regardlng access Lo docLors, Medlcald coverage
does noL correlaLe wlLh beLLer healLh ouLcomes. SLudles show LhaL compared Lo Medlcare paLlenLs,
prlvaLely lnsured paLlenLs, and surprlslngly even unlnsured lndlvlduals, Medlcald reclplenLs have
poorer healLh ouLcomes. lor example, a sLudy conducLed aL Lhe unlverslLy of vlrglnla, and publlshed
ln Lhe Annals of Surgery, found LhaL Medlcald paLlenLs fared raLher poorly, relaLlve Lo Lhose wlLh
prlvaLe lnsurance and even Lhose wlLhouL lnsurance, on a wlde range of measures relaLed Lo surgery
outcomes. Titled, ltlmoty loyet 5totos Affects Mottollty fot Mojot 5otqlcol Opetotloos,
32
the study

32
uamlen !. Laar, M.u., and CasLlgllano M. 8hamldlpaLl, u.C., Carlos M. Mery, M.u., M..P., Ceorge !. SLukenborg, h.u., uavld 8.
MuPPS LogeLher wlLh leglslaLlve
supporL ls ln Lhe mldsL of aLLempLlng
Lo remedlaLe and slmpllfy Lhe
complex operaLlonal long Lerm care
sysLem LhaL has been
lnsLlLuLlonallzed ln Lhe deparLmenL
over Lhe pasL 30 years or more.

age: 24
had a very large sample slze (893,638 ma[or surglcal
operaLlons occurrlng beLween 2003 and 2007) and
conLrolled for age, sex, lncome, geographlc reglon,
operaLlon, and 30 comorbld condlLlons. ?eL lL esLabllshed
LhaL Medlcald paLlenLs experlenced Lhe leasL-deslrable
ouLcomes ln Lerms of ln-hosplLal morLallLy, lengLh of sLay,
and LoLal cosLs. Llkewlse, a sLudy publlshed ln Lhe [ournal
coocet found LhaL Lhe morLallLy raLe for Medlcald paLlenLs
undergolng surgery for colon cancer was more Lhan Lhree
Llmes as hlgh as for Lhose wlLh prlvaLe lnsurance and more Lhan one-fourLh hlgher Lhan for Lhose
wlLh no lnsurance.
33
A sLudy of paLlenLs undergolng lung LransplanLs, ln Lhe Iootool of neott ooJ
looq 1toosploototloo, found LhaL Medlcald paLlenLs were 8.1 less llkely Lo survlve Len years afLer
Lhe surgery Lhan Lhelr prlvaLely lnsured and unlnsured counLerparLs.
34

Conslderlng Lhe poor resulLs from sclenLlflc sLudles on healLh ouLcomes for Medlcald, Lhe quesLlon
for pollcymakers ls wheLher Medlcald oughL Lo be Lhe program of cholce Lo expand healLh lnsurance
coverage.

!ones, M.u., 8ruce u. Schlrmer, M.u., lrvlng L. kron, M.u., and Corav Allawadl, M.u., rlmary ayer SLaLus AffecLs MorLallLy for
Major Surgical Operations, Aoools of 5otqety, SepLember 2010, 232(3): pp. 344331.
33
Slran M. korouklan h.u., and Pual M. Bakaki M.D., M.S., Derek Raghavan M.D., Ph.D., Survlval ulsparlLles by Medlcald SLaLus,
coocet, ubllshed onllne uecember 2011, volume 118, lssue 17, pp. 4271-3279.
34
!eremlah C. Allen, M.u., and Ceorge !. ArnaouLakls, M.u., !onaLhan 8. Crens, M.u., !ohn Mcuyer, M.u., !ohn v. ConLe, M.u.,
Ashlsh S. Shah, M.u., ChrlsLlan A. Merlo, M.u., M..P., Insurance Status is an independent predictor of long-Lerm survlval afLer
lung LransplanLaLlon ln Lhe unlLed SLaLes, 1be Iootool of neott ooJ looq 1toosploototloo. volume 30, lssue 1, pp. 43 33, !anuary
2011.
A sLudy conducLed aL Lhe unlverslLy
of vlrglnla, and publlshed ln Lhe
Annals of Surgery, found LhaL
Medlcald paLlenLs fared poorly,
relaLlve Lo Lhose wlLh prlvaLe
lnsurance and even Lhose wlLhouL
lnsurance, on a wlde range of
measures.
Sect|on III: now States Are Dec|d|ng
age: 23
Sect|on lll: low States Ae Lec|o|ng
v|at States Ae Lo|ng
Accordlng Lo Lhe mosL recenL lnformaLlon avallable, LwenLy-Lwo sLaLes are noL expandlng ellglblllLy
for Medlcald, Lhree sLaLes are currenLly undeclded, and LwenLy-flve sLaLes are expandlng ellglblllLy
ln some form or anoLher. ln Lhe same manner ln whlch Lhe ACA passed lnLo law along parLy llnes,
Lhere appears Lo be a parLlsan paLLern on how sLaLes are decldlng Lo expand. A deLalled Lable locaLed
ln Append|x A ouLllnes acLlons of each sLaLe.
As shown ln I|gure 10, all 13 sLaLes wlLh a uemocraLlc governor and a uemocraL-conLrolled
leglslaLure are expandlng ellglblllLy. Cf Lhe 24 sLaLes wlLh 8epubllcan governors and CC-conLrolled
leglslaLures, mosL are chooslng noL Lo expand ellglblllLy: 18 are noL, 2 are conslderlng, and 4 are
expandlng. 1he currenL excepLlons Lo Lhe general 8epubllcan paLLern are Chlo, Mlchlgan, Arlzona,
and norLh uakoLa, whlch have adopLed or are aLLempLlng Lo adopL some form of expanslon. 1he
remalnlng sLaLes wlLh spllL conLrol beLween Lhe LxecuLlve and LeglslaLlve branches have mlxed
resulLs. AlLhough noL speclfled on Lhe charL, sLaLes whose elecLoraLe voLed for resldenL Cbama ln
Democrat Independent kepub||can
Lxpand|ng 13 1 3 17
Cons|der|ng
Not Lxpand|ng 1 1
Lxpand|ng 2 1 3
Cons|der|ng
Not Lxpand|ng 1 1 2
Lxpand|ng 1 4 S
Cons|der|ng 1 2 3
Not Lxpand|ng 1 18 19
Lxpand|ng 16 1 8 2S
Cons|der|ng 1 2 3
Not Lxpand|ng 2 20 22
19 1 30 S0
S
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|
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o
|

o
f

L
e
g
|
s
|
a
t
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e
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"#$%&' (A) K%551&G +7 FS1. .S' K.1.'6 U&' <+#3$
age: 26
2012 have Lended Lo adopL some form of expanslon wheLher or noL 8epubllcans conLrol Lhe sLaLe
legislature or the governors office.
33

L||g|b|||ty Letem|nat|on C|a||enges
lrom an operaLlonal perspecLlve, sLaLes LhaL are relylng on a federally admlnlsLered healLh care
exchange, whlch lncludes Malne, are experlenclng serlous challenges wlLh deLermlnlng ellglblllLy.
1he uSA 1oday recenLly reporLed LhaL Lhe:
feJetol beoltb cote excbooqe ls locottectly Jetetmloloq tbot some people ote
ellqlble fot MeJlcolJ wbeo tbey cleotly ote oot, leovloq tbem wltb llttle cbooce to
qet tbe sobslJlzeJ losotooce tbey ote eotltleJ to os tbe uec. 2J JeoJlloe fot
eotollmeot opptoocbes. wbeo coosomets opplyloq fot losotooce pot tbelt locome
lofotmotloo loto sobslJy colcolotots oo neoltbcote.qov tbe excbooqe booJlloq
losotooce soles fot J6 stotes lt tells tbem bow mocb floooclol osslstooce tbey
poollfy fot ot tbot tbey ote ellqlble fot MeJlcolJ. lf lt's tbe lottet, coosomets oteo't
oble to obtolo sobslJles towotJ tbe losotooce, oltbooqb tbey coolJ boy foll-ptlceJ
ploos.
36

1he arLlcle also reporLed LhaL people maklng as much as $80,000 a year are belng Lold LhaL Lhey
quallfy for Medlcald on Lhe federal slLe www.PealLhCare.gov.
37

Accordlng Lo Lhe ACA, sLaLes are requlred Lo bulld new ellglblllLy sysLems. 1hese new ellglblllLy
sysLems wlll use daLa sharlng, drawlng from varlous sLaLe and lederal daLa records, Lo populaLe and
verlfy lnformaLlon on Medlcald appllcaLlons and re-cerLlflcaLlons. lf execuLed properly, Lhls wlll
provlde sLaLes wlLh Lhe ablllLy Lo make real-Llme ellglblllLy and enrollmenL deLermlnaLlons, and
mlLlgaLe Lhe need for appllcanLs Lo provlde ln-person
paperwork Lo verlfy lnformaLlon provlded Lo Lhe sLaLe on
Lhelr appllcaLlons. 1he challenge for many sLaLes ls LhaL Lhey
do noL possess a sophlsLlcaLed enough sysLem able Lo
handle Lhe Lype of volume. Malne ls lncluded among Lhose
sLaLes.
38

33
AlLhough Arkansas ls on lLs way Lo expanding Medicaid through what is being described as a private option, the Arkansas
leglslaLure has Lo approve an approprlaLlon each flscal year ln order Lo keep Lhe program ln operaLlon.
36
Jayne ODonnell. lederal exchange sends unquallfled people Lo Medlcald, u5A 1oJoy, uecember 9, 2013.
37
ldem.
38
LllglblllLy sysLems and sLaff are already enormously burdened. lor example llllnols, a sLaLe wlLh a slzeable Medlcald program, ls
[usL one sLaLe LhaL ls experlenclng problems Lrylng Lo remove lnellglbles from Lhelr welfare sysLem rolls. ln facL, Lhe early flndlngs
of an ongolng revlew of Lhe llllnols Medlcald program revealed LhaL half Lhe people enrolled were noL even ellglble. A revlew of
Lhe llllnols Medlcald program conflrms masslve wasLe and fraud. A revlew was ordered more Lhan a year ago-- because of
concerns abouL wasLe and abuse. So far, Lhe sLaLe says revlewers have examlned roughly 712,000 people enrolled ln Medlcald,
and found LhaL 337,000, or abouL half of Lhem shouldn'L have recelved beneflLs. AfLer furLher revlew, Lhe sLaLe declded LhaL Lhe
percenLage of people who dldn'L quallfy was acLually abouL one ouL of four. "lL says LhaL we've had a sysLem LhaL ls dysfuncLlonal.
Cnce people goL on Lhe rolls, Lhere wasn'L Lhe wlll or Lhe means Lo geL them off, said (state) Senator Bill Haines of Alton. A state
.. Lhe federal healLh care
exchange ls lncorrecLly deLermlnlng
LhaL some people are ellglble for
Medlcald when Lhey clearly are
not. u5A 1OuA.
age: 27
Meo|ca|o 8ea||zes Lagest lnceases w|t| t|e ACA
SLaLes are reporLlng hlgher enrollmenL ln Medlcald Lhan ln prlvaLe lnsurance slnce Lhe Affordable
Care AcL exchanges opened CcLober 1, 2013. A new reporL released by Lhe CenLers for Medlcare
and Medlcald Servlces on uecember 3, 2013 reveals LhaL close Lo 1.3 mllllon people were
deLermlned ellglble ln Lhe monLh of CcLober Lo enroll ln Medlcald or Lhe Chlldren's PealLh lnsurance
rogram (CPl).
As one example, ln Lhe sLaLe of WashlngLon, ln Lhe flrsL Lwo monLhs of enrollmenL, Lhe sLaLe's healLh-
care exchangePealLhplanflnderenrolled 176,468 WashlngLonlans ln coverage. Cver 91,000 are
newly ellglble for expanded Medlcald. More Lhan 63,900 were currenLly ellglble buL were noL
enrolled, whlch lefL only 18,000 plus resldenLs who purchased prlvaLe pollcles.
39

1he number of appllcaLlons for Medlcald has lncreased under Lhe
Affordable Care AcL, wlLh growLh more subsLanLlal ln sLaLes LhaL
have declded Lo expand Medlcald. ln sLaLes LhaL are noL expandlng
Medlcald, appllcaLlons Lo Medlcald and CPl lncreased 4.1 ln
CcLober over Lhe prevlous few monLhs, and Lhe LoLal number of
lndlvlduals deLermlned Lo be ellglble for Medlcald or CPl was
697,019. ln expanslon sLaLes, appllcaLlons [umped 13.3, and
737,991 new ellglblllLy deLermlnaLlons were made. 1he LoLal
across all sLaLes was an 8.6 lncrease ln appllcaLlons and
1,460,367 new ellglblllLy deLermlnaLlons.
60

1hls daLa lndlcaLes LhaL even wlLhouL expanslon, Malne wlll see a subsLanLlal lncrease of newly
ellglble lndlvlduals.
61

spokesman lnslsLs LhaL Lhe percenLage of unquallfled reclplenLs wlll conLlnue Lo drop dramaLlcally as Lhe revlew conLlnues
because Lhe beglnnlng of Lhe process focused on Lhe people LhaL were mosL llkely Lo be unquallfled for Lhose beneflLs. 1ed
uabrowskl, a vlce-resldenL of 1he llllnols ollcy lnsLlLuLe Lhlnk Lank, spoke wlLh news 4 vla Sk?L. Pe sald Lhe Medlcald revlew
found Lwo ouL of Lhree reclplenLs elLher goL Lhe wrong beneflLs, or dldn'L deserve any at all. We added so many people to
Medicaid rolls so quickly, we've lost control of who belongs there, said Dabrowski. But regardless of how it ends, critics say lL ls
proof LhaL llllnols has done a poor [ob of protecting tax payers money, adapLed from Channel 4 kMCv.com, SL. Louls, accessed
aL: hLLp://www.kmov.com/news/[usL-posLed/AudlL-reveals-half-of-people-enrolled-ln-lL-Medlcald-program-noL-ellglble-
230386321.hLml.
39
WashlngLon Slgnlng up More eople for Medlcald Lhan rlvaLe lans. cotbollc Oolloe. uecember 6, 2013.
60
CenLers for Medlcare and Medlcald Servlces. Medlcald and CPl: CcLober MonLhly AppllcaLlons and LllglblllLy ueLermlnaLlons.
uecember 3, 2013.
61
lbld, 1able 1, CcLober AppllcaLlons and LllglblllLy ueLermlnaLlons.
SLaLes are reporLlng hlgher
enrollmenL ln Medlcald Lhan
ln prlvaLe lnsurance slnce Lhe
Affordable Care AcL
exchanges opened CcLober 1,
2013. 1he growLh ls more
subsLanLlal ln sLaLes LhaL
have declded Lo expand
Medlcald.
age: 28
Se|ecteo State l|g|||g|ts o 8ecent Act|v|ty
62

Lxpanslon sLaLes are already seelng a large number of lndlvlduals enrolled ln Medlcald. Many of
Lhese lndlvlduals are prequallfled for expanded Medlcald because Lhey are already enrolled ln oLher
enLlLlemenL programs such as food sLamps.
63
lor example, ln Cregon, 70,000 resldenLs have
enrolled as a resulL of aggresslve ouLreach campalgns Lo Lhose who recelve food sLamps ln Lhe sLaLe.
CLher sLaLes have followed slmllar adverLlsemenL campalgns wlLh varled success.
Ar|zona: 1he number of new appllcaLlons ls noL avallable aL Lhls Llme. ln LoLal, Arlzona expecLs
37,000 people Lo quallfy for lLs expanded Medlcald program. ln addlLlon, Lhe sLaLe expecLs 240,000
more lndlvlduals Lo enroll ln lLs exlsLlng Medlcald program for chlldless adulLs wlLh lncomes aL or
below Lhe federal poverLy level. LnrollmenL ln LhaL program was frozen ln 2012 aL 70,000.
Arkansas: Arkansas elecLed Lo expand lLs Medlcald program from 17 of lL Lo 138 of lL.
64

Arkansas has recelved 70,393 appllcaLlons for lLs expanded Medlcald program. Cf Lhose, 3,672 came
Lhrough Lhe sLaLe's exlsLlng Medlcald webslLe, 1,783 were paper or phone appllcaLlons, and Lhe resL
were poslLlve responses Lo a malllng Lo 132,000 households LhaL recelve food sLamps. ulLlmaLely,
Lhe sLaLe expecLs abouL 230,000 unlnsured resldenLs Lo quallfy for Medlcald.
63

Ca||forn|a: newly ellglble enrollmenL ln expanded Medlcald ls expecLed Lo LoLal abouL 1.4 mllllon.
Cf LhaL number, 600,000 people wlll come from Lhe sLaLe's early expanslon program approved by
Lhe federal governmenL ln 2011.
Co|orado: Colorado has quallfled more Lhan 23,000 adulLs for lLs expanded Medlcald program. Cf
LhaL number, approxlmaLely 9,000 were on a walLlng llsL for an exlsLlng Medlcald program LhaL
covers adulLs wlLh exLremely low lncomes. AnoLher 10,000 people enrolled ln LhaL program wlll also
be Lransferred Lo expanded Medlcald coverage ln !anuary. Comblned, LhaL comes Lo 33,000
lndlvlduals, more Lhan 20 of Lhe 160,000 unlnsured resldenLs Colorado expecLs Lo be ellglble for
lLs expanded Medlcald program.

62
MosL lnformaLlon modlfled from ewsLaLes.org lnformaLlon on Lhe sLaLes.
63
LxpedlLlng Lhe ellglblllLy process does noL necessarlly LranslaLe lnLo program lnLegrlLy.
64
SLaLes llke Malne, MassachuseLLs, and vermonL already possessed expanded populaLlons prlor Lhe ACA whereas sLaLes llke
Arkansas dld noL.
63
Arkansas ls one of Lhe flrsL sLaLes Lo use a new Lool for faclllLaLlng expedlLed Medlcald enrollmenL. 1he sLaLe ls uslng lnformaLlon
lL already had on hand such as SupplemenLal nuLrlLlonal AsslsLance rogram (SnA) lncome daLa Lo conducL an expedlLed
(express) administrative transfers to Medicaid. To implemenL Lhe sLraLegy, Arkansas senL leLLers Lo SnA parLlclpanLs leLLlng
Lhem know Lhey are poLenLlally ellglble for Medlcald and lnvlLlng Lhem Lo enroll by respondlng Lo Lhe leLLer. 1o enroll, Lhe person
reLurns a slmple form and Lhe sLaLe conducLs addlLlonal daLa checks, as approprlaLe. Slnce Lhe sLaLe began sendlng leLLers ln
early September, Arkansas reports that 63,465 individuals have been fast tracked into Medicaid wlLh llLLle walL. uurlng Lhe
same perlod of Llme, Lhe sLaLe also found 3,000 unenrolled children who are eligible for ARKids First, the states Medicaid and
CPl programs. CenLers for Medlcare and Medlcald Servlces, Medlcald and CPl: CcLober MonLhly AppllcaLlons and LllglblllLy
ueLermlnaLlons, uecember 3, 2013, p. 3.
age: 29
Connect|cut: ConnecLlcuL has enrolled 3,330 new people ln lLs expanded Medlcald program Lhrough
lLs sLaLe-run exchange and Medlcald webslLe. ln addlLlon, aL leasL 48,000 enrolled ln a sLaLe-run low
lncome-healLh program have already been moved lnLo expanded Medlcald. ConnecLlcuL expecLs a
LoLal of 33,000 expanded Medlcald enrollees ln 2014.
De|aware: no new enrollmenL daLa ls avallable yeL. uelaware already provldes Medlcald coverage
for 30,000 adulLs wlLh lncomes up Lo Lhe federal poverLy level ($11,490). lLs expanded Medlcald
program ls expecLed Lo cover anoLher 30,000 people wlLh lncomes beLween $11,490 and 138 of
Lhe federal poverLy level ($13,836).
D|str|ct of Co|umb|a: u.C. began expandlng lLs Medlcald program ln !une 2010. 8y !une 2013, nearly
30,000 new people were enrolled. 1he ulsLrlcL has noL esLlmaLed how many people wlll ulLlmaLely
enroll ln expanded Medlcald.
nawa||: Pawall has approved 6,100 appllcaLlons for expanded Medlcald. 8y 2014, Lhe sLaLe expecLs
a LoLal of 34,000 enrollees.
I|||no|s: 1he llllnols Medlcald agency has recelved 30,124 appllcaLlons for expanded Medlcald
Lhrough lLs exlsLlng webslLe. llllnols has an exchange parLnershlp wlLh Lhe federal governmenL so
appllcaLlons are also belng flled on Lhe federally-run exchange. ln addlLlon Lo onllne appllcaLlons,
46,000 people responded Lo an AugusL malllng Lo 123,000 food sLamp reclplenLs. llllnols has enrolled
26,000 of Lhose respondenLs and ls processlng Lhe balance. ln addlLlon, 100,000 people ln Cook
CounLy who parLlclpaLed ln a llmlLed early Medlcald expanslon enrollmenL group wlll auLomaLlcally
be rolled over Lo Lhe expanslon program on !anuary 1, 2014. ro[ecLed enrollmenL ls 342,000.
Iowa: no new numbers are avallable on Medlcald appllcaLlons. ln all, 130,000 unlnsured lowans are
expecLed Lo quallfy under Lhe proposed expanslon. AbouL 63,000 resldenLs wlLh lncomes up Lo 200
of Lhe federal poverLy level ($22,980) are currenLly enrolled ln a Medlcald healLh plan wlLh llmlLed
beneflLs. MosL are expecLed Lo quallfy for expanded Medlcald. lowa has noL yeL recelved federal
approval for lLs Medlcald expanslon plan, whlch ls slmllar Lo Arkansas' so-called prlvaLe opLlon.
Iowas Medicaid expansion was recently granted partial approval on December 10, 2013.
kentucky: kenLucky has recelved 23,634 appllcaLlons for expanded Medlcald Lhrough lLs sLaLe-run
exchange. ulLlmaLely, Lhe sLaLe expecLs 308,000 low-lncome lndlvlduals Lo quallfy.
Mary|and: 1he number of appllcaLlons from lLs sLaLe-run webslLe ls noL yeL avallable. Powever,
Maryland has an exlsLlng, llmlLed-beneflL healLh plan known as rlmary AdulL Care (AC) avallable
Lo all adulLs wlLh lncomes up Lo 123 of Lhe federal poverLy level ($14,133). As of SepLember 30,
enrollmenL ln Lhe plan was 82,423. Maryland expecLs enrollmenL ln AC Lo expand Lo 88,000 by
!anuary 1, 2014, when Lhe enLlre AC populaLlon wlll auLomaLlcally converL Lo full Medlcald beneflLs.
ln addlLlon, resldenLs ln a narrow lncome band (124 Lo 138 of poverLy) can slgn up for expanded
age: 30
Medlcald on Lhe sLaLe exchange. Cverall, Maryland expecLs 110,000 people Lo be enrolled by Lhe
end of 2014.
Massachusetts: no enrollmenL numbers are avallable aL Lhls Llme. As a resulL of lLs own healLh care
reforms launched ln 2006, MassachuseLLs has a 97 lnsured raLe. SLlll, Lhe sLaLe expecLs abouL
43,000 people Lo obLaln Medlcald coverage as a resulL of Lhe expanslon.
M|ch|gan: no enrollmenL numbers are avallable. 1he Mlchlgan leglslaLure approved 8epubllcan
Covernor 8lck Snyder's proposed Medlcald expanslon ln SepLember buL posLponed lmplemenLaLlon
unLll Aprll 2014.
M|nnesota: 1he federal governmenL granLed MlnnesoLa speclal permlsslon Lo enroll 84,000
lndlvlduals ln Lhe expanded Medlcald program ln 2011. AnoLher 2,496 newly ellglble Medlcald
members compleLed appllcaLlons on Lhe sLaLe-run exchange ln Lhe flrsL Lwo weeks of CcLober.
ulLlmaLely, MlnnesoLa expecLs Lo cover 263,000 adulLs ln lLs expanslon. ln addlLlon, lL ls Lhe only
sLaLe LhaL has opLed Lo provlde a so-called "8aslc PealLh lan" for people wlLh lncomes up Lo 200
of Lhe federal poverLy llne ($22,980). under Lhe ACA, Lhe federal governmenL wlll pay 83 of Lhe
cosLs sLarLlng ln 2013. 1haL program ls expecLed Lo grow Lo 160,000.
New nampsh|re: 1he Covernor called a speclal sesslon Lo conslder Medlcald Lxpanslon and on
november 21, 2013, Speclal Pouse 8lll 1 Lo expand Medlcald, approved by Lhe Pouse early ln Lhe
day, was re[ecLed by Lhe SenaLe. Powever, spokespersons for boLh parLles have sLaLed LhaL
negoLlaLlons would conLlnue ln Lhe 2014 general sesslon. 1hey expressed lnLeresL ln conslderlng bllls
LhaL lnclude provlslons Lo use federal Medlcald funds Lo buy prlvaLe lnsurance for mosL of Lhe newly-
ellglble adulLs as well as a new sLaLe-managed care program for oLher adulLs.
New Mex|co: new Mexlco has approved 2,307 appllcaLlons for expanded Medlcald Lhrough Lhe
federally operaLed exchange and lLs exlsLlng Medlcald webslLe. ln addlLlon, 100,000 enrollees ln Lwo
llmlLed-beneflL sLaLe healLh care programs wlll be rolled lnLo Lhe expanded Medlcald. new Mexlco
expecLs 130,000 people wlll be ln Lhe expanded program by 2013.
New ork: no enrollmenL numbers are avallable yeL. new ?ork already covers parenLs wlLh lncomes
up Lo 130 of Lhe federal poverLy llne ($17,233) and chlldless adulLs wlLh lncomes up Lo Lhe federal
poverLy level ($11,490).
North Dakota: 1he Medlcald agency has recelved 147 appllcaLlons for expanded Medlcald. ln
uecember, Lhe sLaLe plans Lo send leLLers Lo 36,000 households LhaL recelve food sLamps or home
heaLlng asslsLance, lnvlLlng ellglble adulLs Lo slgn up for expanded Medlcald. 1oLal enrollmenL ln
expanded Medlcald ls expecLed Lo reach 32,000.
age: 31
Ch|o: 1he mosL recenL sLaLe Lo expand Medlcald, Chlo expecLs Lo slgn up 273,000 newly ellglble
Medlcald enrollees. 8epubllcan Covernor !ohn kaslch sldesLepped Lhe sLaLe leglslaLure and won
approval for expanslon on CcLober 21, 2013, from an execuLlve branch ConLrolllng 8oard. 1he sLaLe
has noL yeL begun enrollmenL. 1he Medlcald agency says lL wlll announce soon when enrollmenL wlll
begln.
Cregon: Cregon has approved 70,000 appllcaLlons for expanded Medlcald. lLs sLaLe-run webslLe had
some lnlLlal Lechnlcal dlfflculLles, buL new appllcaLlons were flled over Lhe phone, ln person, and
Lhrough Lhe mall. 1he vasL ma[orlLy of enrollmenLs came from a malllng ln laLe SepLember LhaL wenL
Lo 260,000 resldenLs who elLher recelve food sLamps or have chlldren enrolled ln Medlcald. 1he
sLaLe expecLs roughly 223,000 adulLs Lo be enrolled ln lLs expanded Medlcald program by 2013.
ennsy|van|a: As of Lhe wrlLlng of Lhls documenL, ennsylvanlas plan had not formally been
crafLed. ennsylvanla ls plannlng Lo submlL an 1113 walver and model lLs reforms afLer Lhe Arkansas
plan by, lncreaslng access Lo prlvaLe markeL coverage Lhrough Lhe neoltby leoosylvoolo rlvaLe
Coverage CpLlons for ennsylvanlans 21 years of age or older buL under 63 years of age wlLh
lncomes up Lo 138 of Lhe lederal overLy Level (lL), reallgnlng Lhe exlsLlng Medlcald beneflL plan
deslgns Lo provlde healLh coverage based on healLh care needs, and promoLlng healLhy behavlors
and lmproved healLh ouLcomes Lhrough a cosL sharlng deslgn and work search acLlvlLles.
khode Is|and: 8hode lsland has approved 3,213 new appllcaLlons for lLs expanded Medlcald
program. AnoLher 833 are ln progress. ro[ecLed enrollmenL ls 23,428.
Vermont: AbouL 1,000 lndlvlduals have slgned up for Medlcald on vermonL's exchange or by
submlLLlng paper appllcaLlons. ln addlLlon, 30,000 adulLs enrolled ln Lwo sLaLe-run low-lncome
healLh plans wlll be rolled lnLo Lhe expanded Medlcald program. 8y 2013, vermonL expecLs
enrollmenL Lo reach 160,000.
Wash|ngton: 1hrough lLs sLaLe-run exchange and Medlcald slLes, WashlngLon has slgned up 26,336
people. AnoLher 30,000 people enrolled ln a low-lncome healLh program wlll be auLomaLlcally
enrolled ln expanded Medlcald, brlnglng Lhe LoLal Lo 36,336. 1he sLaLe expecLs 270,000 people Lo
quallfy by Lhe end of 2014.
West V|rg|n|a: WesL vlrglnla has pre-quallfled 32,036 resldenLs for lLs expanded Medlcald program.
ro[ecLed new enrollmenL ls 63,000.

age: 32


Sect|on IV: Ma|neCare Cverv|ew
age: 33
Sect|on lv: Ma|neCae Cvev|ew
Lemogao||c lmoact
uemographlc changes are lmporLanL facLors noL only for deLermlnlng enrollmenL ln Medlcald
programs buL also for esLlmaLlng Lhe lmpacL on speclflc programs wlLhln Medlcald. 1hls ls especlally
Lrue for Lhe demographlc facLors of age dlsLrlbuLlon and poverLy.
Musk|e Schoo| opu|at|on ro[ect|ons
66

ln Lhe case of Malne, lL has Lhe Lhlrd mosL aged populaLlons ln
Lhe counLry, and as of 2012, one flfLh, or 17, of Maines
populaLlon was age slxLy flve and older.
67
1he Muskle School of
ubllc Servlce of Lhe unlverslLy of SouLhern Malne pro[ecLs LhaL
persons age 63 and older wlll grow by an esLlmaLed 46.3,
fasLer Lhan any oLher segmenL of Lhe populaLlon, and lL would
consLlLuLe mosL of Lhe sLaLes populaLlon growLh over Lhe nexL
Len years.
68
I|gure 11 shows how Lhe Malne populaLlon by age

66
!. lrallch, eL. al., Clder AdulLs and AdulLs wlLh ulsablllLles: opulaLlon and Servlce use 1rends ln Malne, cbottbook, 2012 LdlLlon,
llgure 12, p. 2. 2012, accessed aL: hLLp://muskle.usm.malne.edu/uA/AdulLs-ulsablllLles-Malne-Servlce-use-1rends-charLbook-
2012.pdf
67
lbld, pp. 1 and 4.
68
ldem. noLe LhaL Lhe cbottbook reported nearly 99% of the states population growth would be in the age category of 65 and
older. AlLhough Lhls calculaLlon ls correcL when age brackeLs are aggregaLed ln Lhls manner, lL may be mlsleadlng by glvlng Lhe
false lmpresslon LhaL no caLegory below 63 ls pro[ecLed Lo have growLh when ln facL four of Lhose slx age caLegorles are pro[ecLed
Lo have slgnlflcanL growLh. 1he calculaLlon works LhaL way because Lhe age caLegorles of 13-24 and 43-34 are pro[ecLed Lo have
negaLlve growLh, whlch negaLes Lhe growLh ln Lhe remalnlng four caLegorles under age 63. erhaps a beLLer way Lo represenL Lhe
"#$%&' (() *&+,'-.'/ IS13$'6 #3 01#3'Y6 U$' *&+7#4' 7&+5 8A(8 .+ 8A88
ln Lhe case of Malne, lL has
Lhe Lhlrd mosL aged
populaLlon ln Lhe counLry, and
as of 2012, one flfLh, or 17,
of Maines population was
age slxLy flve and older.
age: 34
caLegory wlll change Lhrough 2022.
69
1he demographlc dlsLrlbuLlon of age ls an lmporLanL
deLermlnanL on Medlcald expendlLures whereas older lndlvlduals Lend Lo have more chronlc
lllnesses and requlre more servlces.
ln regard Lo poverLy, Malne recenLly has had slgnlflcanL growLh. Accordlng Lo daLa from Lhe Small
Area lncome and overLy LsLlmaLes (SAlL) of Lhe u.S. Census 8ureau, Lhere were 186,484 persons
llvlng ln poverLy, and 31,386 of Lhem were chlldren. (See I|gure 12.)
Although Maines overall population growth has been somewhaL slow, growlng only 4.2 beLween
Lhe lasL Lwo decennlal censuses for an average annual raLe of 0.41, lLs poverLy level has been
lncreaslng dramaLlcally. Chlldren had a poverLy raLe of 12.9 ln 2000 buL a poverLy raLe of 19.8 ln
2012. 1oday one ln flve chlldren ln Malne llves ln poverLy. 1he poverLy raLes are also worsenlng for
Lhe adulL populaLlon as can be seen ln I|gure 13 and I|gure 14.
1he growLh ln poverLy cannoL be fully explalned by Lhe lasL economlc recesslon. ln order Lo reduce
Lhe skewlng of daLa due Lo Lhe lmpacL of economlc recesslons, Lwo daLes were chosen aL slmllar
polnLs along Lhe buslness cycle: 2000 and 2007. 1hese daLes are lmmedlaLely before Lhe peaks of
Lhe buslness cycles. 1he SAlL daLa for 2000 was collecLed prlor Lo Lhe 2001 recesslon LhaL began
monLh afLer Lhe peak of March 2001, and Lhe SAlL daLa for 2007 preceded Lhe recesslon LhaL began

growLh would be Lo exclude Lhe Lwo age caLegorles wlLh negaLlve growLh, glvlng Lhe resulL of approxlmaLely 70 of Lhe growLh
aLLrlbuLed Lo age caLegory of 63 and older.
69
lbld, p. 2.
A|| overty
Not
overty
A|| overty
Not
overty
A|| overty
Not
overty
2000 to 2007 0.22 3.23 -0.13 -0.47 2.37 -0.94 0.41 3.37 0.06 4.96
2007 to 2012 0.19 3.67 -0.33 -1.09 3.60 -2.07 0.32 3.69 0.09 2.17
1ota| opu|at|on Ch||dren 0 - 17 Adu|ts (18 & over)
1rad|t|ona|
Ma|neCare
Ma|ne Average Annua| opu|at|on Growth
Small Area lncome and overLy LsLlmaLes of Lhe u.S. Census 8ureau
"#$%&' (8) *+P'&.G #6 1 I&#.#-14 X66%' 7+& 01#3'
"#$%&' (=) 01#3' *+:%41.#+3 13/ *+P'&.G @&'3/6 7+& Z'1&6 8AAA Q 8A(8
ear 1ota| Adu|ts Ch||dren
2000
124,727 88,187 36,340
2007
133,764 112,712 43,032
2010
169,076 120,342 48,734
2012 186,484 133,098 31,386
ersons |n overty |n Ma|ne
Small Area lncome and overLy LsLlmaLes of Lhe u.S. Census 8ureau
age: 33
Lhe monLh afLer Lhe peak of november 2007.
70
Powever, over LhaL Llme span, SAlL daLa show Lhe
adulL populaLlon ln poverLy grew 3.37 annually compared Lo 0.06 for Lhose adulLs oot ln poverLy.
(See I|gure 14.) lor chlldren ln poverLy, Lhe annual growLh raLe was 2.37 compared Lo negaLlve
value of 0.94 for Lhose chlldren oot in poverty. These trends have serious implications for Maines
welfare programs and slgnlflcanLly lmpacL Lhe ouLcome of scenarlos generaLed by Lhe flnanclal
model dlscussed ln Sect|on V of Lhls reporL.
1he growLh ln poverLy ls more Lhan slmply a flscal concern. 1here are no shorLages of sLudles LhaL
llnk poverLy Lo lncreases ln poor healLh. SLudles lndlcaLe LhaL poverLy levels dlrecLly correlaLe wlLh
low blrLh welghLs, whlch can resulL ln lncreased lnfanL morLallLy
raLes as well as developmenLal lssues ln chlldren. A sLudy
compleLed by ur. 8arbara SLarfleld provlded evldence LhaL poverLy
levels have long-Lerm effecLs. 1he sLudy noLed LhaL when one
blrLh ls of low blrLh welghL and Lhe moLher ls poor, Lhe llkellhood
of the next infant being of low birth weight exceeds 40%.
71
1he
Amerlcan hyslologlcal AssoclaLlon found LhaL chlldren llvlng ln
poverLy are aL greaLer rlsk of behavloral and emoLlonal problems

70
uaLes used for Lhe sLarL of recesslons are calculaLed by Lhe 8uslness Cycle uaLlng CommlLLee of Lhe naLlonal 8ureau of Lconomlc
8esearch.
71
Barbara Starfield, M.D. M.P.H., LffecLs of Poverty on Health Status, 8olletlo of tbe New otk AcoJemy of MeJlcloe, 2012,
occessed aL: hLLp://www.ncbl.nlm.nlh.gov/pmc/lssues/142739/a.
"#$%&' (?) 01#3' *+P'&.G 16 *'&-'3. +7 *+:%41.#+3
SLudles lndlcaLe LhaL poverLy
levels dlrecLly correlaLe wlLh
low blrLh welghLs, whlch can
resulL ln lncreased lnfanL
morLallLy raLes as well as
developmenLal lssues ln
chlldren .
2
0
0
0
9
.
9
2
0
0
0
9
.
0
2
0
0
0
1
2
.
9
2
0
0
7
1
2
.
2
2
0
0
7
1
1
.
2
2
0
0
7
1
S
.
7
2
0
1
0
1
3
.
1
2
0
1
0
1
1
.
7
2
0
1
0
1
8
.
2
2
0
1
2
1
4
.
4
2
0
1
2
1
3
.
1
2
0
1
2
1
9
.
8
0
S
10
1S
20
1ota| Adu|ts Ch||dren
e
r
c
e
n
t

|
n

o
v
e
r
t
y
Ma|ne overty kates
2000 2007 2010 2012
Cne |n f|ve ch||dren ||ves |n poverty.
SAlL daLa, u.S. Census 8ureau
age: 36
and developlng oLher menLal healLh lssues, such as anxleLy, depresslon, and aLLenLlon
deflclL/hyperacLlvlLy dlsorders.
72
1hls sLudy clearly supporLs why Lhe cosLs of menLal healLh and
neurologlcal dlsorders are lncreaslng. 1hese Lwo areas of servlce are Malne Cares Lop Lwo
caLegorles of spendlng. lnformaLlon obLalned from MuPPS reveal LhaL MenLal PealLh servlces ls Lhe
Lop cllnlcal condlLlon for 93 of MalneCare members and second only Lo neurologlcal ulsorders.
73

overLy may also be llnked Lo Lhe overall feellng of well-belng. 1he CenLers of ulsease ConLrol and
revenLlon (CuC), uSuPPS, capLures daLa and reporLs on healLh-relaLed quallLy of llfe. 1he CuC has
made correlaLlons beLween well-belng, l.e., how healLhy a person feels, relaLlve Lo medlcal cosLs.
1hey reporLed LhaL on average ln 2009 Malners felL unhealLhy, elLher physlcally or menLally, abouL
slx days a monLh. 1he CuC also found LhaL younger adulLs, aged 18-24, suffered Lhe mosL menLal
healLh dlsLress and older adulLs suffered Lhe mosL poor physlcal healLh and acLlvlLy llmlLaLlon. 1hls
number lncreased as Lhe lncome and educaLlon levels of adulLs dropped. 1he map ln I|gure 1S
shows mean unhealLhy days for Lhe unlLed SLaLes ln 2009. 1hese numbers are hlgher ln 2010.
74

72
8ased on lnformaLlon accessed Lhrough Lhe Amerlcan sychologlcal AssoclaLlon webslLe on Lhe LffecLs of overLy, Punger, and
Pomelessness on Chlldren and ?ouLh. See hLLp://www.apa.org/pl/famllles/poverLy.aspx.
73
ldem.
74
CenLers for ulsease ConLrol and revenLlon, PealLh-8elaLed CuallLy of Llfe (P8CCL). Figure 2: Mean number of reported
physlcally unhealLhy days ln Lhe pasL 30 days by sLaLe, accessed aL: hLLp://www.cdc.gov/hrqol/daLa/maps/flgure2-
"#$%&' (H) K.1.' LG K.1.' 0'13 J3S'14.SG <1G6 #3 B16. =A <1G6
age: 37
Ma|neCae uuogetay Cvev|ew
Accordlng Lo daLa provlded by MuPPS, MalneCare spendlng ln LoLal funds, lncludlng federal funds,
for boLh servlces and admlnlsLraLlve cosLs was $2.7 bllllon ln Sl? 2012-13, accounLlng for a LoLal of
79 of Lhe LoLal MuPPS agency budgeL. (See I|gure 16.)
lor Lhe Ceneral lund only, MalneCare was $1.1 bllllon or 73 of Lhe departments General Fund
budgeL. (See I|gure 17.)

meanphyslcallyunhealLhy.hLm.
"#$%&' (N) 01#3' <[[K ;%/$'.U44 "%3/6

Cther
5724 M||||on
21
Ma|neCare
52.7 8||||on
79
MDnnS SI 13 8udget
ALL IUNDS (Inc|ud|ng Iedera|)
"#$%&' (R) 01#3' <[[K ;%/$'.>'3'&14 "%3/ OTBZ
age: 38
ln addlLlon Lo recelvlng fundlng from Lhe Ceneral lund and Lhe federal governmenL, MalneCare
also recelves revenue ln excess of $230 mllllon from Lhe oLher speclal revenue sources, whlch
lncludes Lhe followlng:

1he Medlcal Care Servlces 1ax AccounL
1he Medlcal Care PosplLal 1ax AccounL
1he nurslng laclllLles 1ax AccounL
1he lund for a PealLhy Malne
MalneCare Servlces conLlnue Lo comprlse slgnlflcanL proporLlons of sLaLe revenue sources. lor Sl?
2012-13, 24.2 of Lhe Ceneral lund was expended on MalneCare Servlces, 19.0 of all sLaLe funds,
lncludlng Lhe Plghway lund and oLher speclal revenue funds, were expended on MalneCare, 39.2
of all federal funds recelved by Lhe sLaLe governmenL were dedlcaLed Lo MalneCare Servlces, and,
32.2 of Lhe LoLal of all funds spenL were expended on MalneCare Servlces. (See I|gure 18.)
ln LoLal dollars spenL, MalneCare ls Lhe largesL budgeL lLem. When focuslng on [usL Lhe Ceneral lund,
elemenLary and secondary educaLlon ls Lhe largesL budgeL lLem. Powever, when Lhe oLher speclal
revenue funds are added Lo Lhe Ceneral lund, lL adds anoLher $233 mllllon ln sLaLe funds Lo supporL
MalneCare, brlnglng Lhe MalneCare sLaLe cosL wlLhln Len percenL of Lhe LoLal elemenLary and
secondary educaLlon budgeL. When federal funds are lncluded, MalneCare spends $1.93 for every
dollar spenL on elemenLary and secondary educaLlon. (See I|gure 19.)
24.2
19.0
S9.2
32.2
0
10
20
30
40
S0
60
Genera| Iund A|| State Iunds Iedera| Iunds 1ota| Iunds
Ma|neCare Serv|ces as ercent of Iund|ng Source
"#$%&' (V) 01#3'I1&' 16 *'&-'3. +7 "%3/#3$ K+%&-'
age: 39
As a percenL of LoLal budgeLary funds, Lhe Lwo largesL
budgeLary lLems comprlse 33.7 (elemenLary and
secondary educaLlon) and 24.2 (MalneCare) of Lhe
Ceneral lund, leavlng only 40.1 of Lhe Ceneral lund
for all remalnlng governmenL funcLlons LhaL need Lo be
funded from Lhe Ceneral lund. (See I|gure 20). When
Lhe Plghway lund and oLher speclal revenue funds are
lncluded, Lhe Lwo largesL budgeLary lLems comprlse 21.0 and 19.0, respecLlvely, leavlng only
60.0 for all oLher governmenL funcLlons. When federal funds are added, Lhen Lhe Lwo largesL
budgeLary lLems swlLch places, wlLh MalneCare accounLlng for 32.2 of all fundlng and elemenLary
24.2
19.0
32.2
3S.7
21.0
16.7
0
10
20
30
40
S0
60
70
80
90
100
Genera| Iund Genera| Iund |us
Spec|a| kevenue
Iunds
A|| Iunds, |nc|ud|ng
Iedera|
ercent Spent of 8udgetary Iunds
Ma|neCare L|ementary and Secondary Lducat|on kest of 8udget
ln Sl? 2012-13 lf federal funds are
lncluded, Lhe Lwo largesL budgeLary
lLems are MalneCare aL 32.2 of all
fundlng and elemenLary and secondary
educaLlon accounLlng for 16.7.
50.0
50.S
51.0
51.S
52.0
52.S
53.0
Ma|neCare L|ementary and
Secondary Lducat|on
8
|
|
|
|
o
n
s

L
x
p
e
n
d
e
d

|
n

S
I

2
0
1
2
-
1
3
Compar|ng Ma|neCare Serv|ces to
Support for ub||c Schoo|s
Iedera| Iunds
Cther State Iunds
Genera| Iund
"#$%&' (W) *'&-'3. K:'3. +7 ;%/$'.1&G "%3/6
"#$%&' 8A) I+5:1&#3$ 01#3'I1&' .+ *%L4#- K-S++46 K%::+&.
age: 40
and secondary educaLlon accounLlng for 16.7
Maines high level of Medicaid expenditures is high relative to what
oLher sLaLes are spendlng. Compared Lo oLher new Lngland sLaLes,
Malne spends more of lLs
LoLal budgeL on Medlcald.
(See I|gure 21.)
73

Cver Lhe pasL Len years, sLaLe funds supporLlng MalneCare
servlces have grown more rapldly Lhan growLh ln lederal
expendlLures supporLlng MalneCare. Average annual
expendlLure growLh for MalneCare Servlces has been nearly
Lrlple Lhe resL of Lhe budgeL. lor Lhe Ceneral lund, MalneCare
Servlces grew over Lhe pasL Len years aL an average raLe of
3.7, compared Lo only 1.3 for Lhe resL of Lhe Ceneral lund
budgeL. (See I|gure 22.)
76
lor all sLaLe funds, Lhe growLh raLe
for MalneCare Servlces was 6.0 compared Lo 2.2 for Lhe
resL of Lhe sLaLe budgeL. lor federal funds, lL was only 2.6
growLh for MalneCare Servlces, compared Lo 2.3 growLh for Lhe resL of Lhe budgeL. ln LoLal,
lncludlng all funds, Lhe growLh raLe for MalneCare servlces was 3.8 compared Lo 2.2 for Lhe resL

73
naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers, SLaLe LxpendlLure 8eporL: Lxamlnlng llscal 20112013 SLaLe Spendlng, 2013.
Also, as already presenLed earller ln Lhls reporL, Malne has Lhe Lhlrd hlghesL spendlng on Medlcald ln Lhe naLlon.
76
ldem.
"#$%&' 88) @'3 Z'1& U33%14 ;%/$'. >&+E.S I+5:1&#6+36
3.7
6.0
2.6
3.8
1.3
2.2
2.S
2.2
0.0
1.0
2.0
3.0
4.0
S.0
6.0
Genera| Iund A|| State Iunds Iedera| Iunds 1ota| Iunds
1en-ear Average Annua| 8udget Growth
Ma|neCare Serv|ces kest of the 8udget
MalneCare servlces exclude admlnlsLraLlve cosLs.
uaLa Source: naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers
Compared Lo oLher new
Lngland sLaLes, Malne
spends more of lLs LoLal
budgeL on Medlcald.
State ercent
Malne 32.2
vermonL 28.0
new Pampshlre 23.6
8hode lsland 24.4
ConnecLlcuL 22.0
MassachuseLLs 21.3
Med|ca|d Lxpend|tures as a
ercent of 1ota| Lxpend|tures
(NAS8C 2013)
"#$%&' 8() New England States
29:'3/#.%&'6 +3 0'/#-1#/ Q *'&-'3. +7
@+.14
age: 41
of Lhe budgeL.
leoea| Meo|ca| Ass|stance lecentage (lMAl)
1he lMA raLe ls Lhe mechanlsm used by Lhe federal governmenL Lo asslsL sLaLes ln fundlng Lhelr
Medlcald program. SecLlon 1903(b) of Lhe Soclal SecurlLy AcL speclfles a formula for calculaLlng Lhe
federal asslsLance percenLages. 1he formula Lakes lnLo accounL Lhe average per caplLa lncome for
each sLaLe relaLlve Lo Lhe naLlonal average. 8y law, lMA raLes cannoL be less Lhan flfLy percenL.
77

1he federal governmenL has used enhanced federal asslsLance percenLages or lncreases Lo a sLaLe
base raLe Lo asslsL Lhe sLaLe ln offseLLlng Lhe budgeLary demand for publlc welfare, buL ln recenL
hlsLory due Lo lLs own budgeLary demands, Lhe federal governmenL has reduced and ellmlnaLed
many enhanced maLch raLes and lowered many
sLaLes base raLes.
78

lor example, ln Malne, lMA raLes have decllned
slnce 2000. A sllghL lncrease ln 2010 was due Lo
addlLlonal federal fundlng avallable ln Lhe fourLh
quarLer and noL an acLual long-Lerm lncrease ln Lhe
sLaLes lMA raLe. Lach percenLage-polnL drop ln
Lhe lMA raLe resulLs ln approxlmaLely $23 mllllon ln reduced federal parLlclpaLlon, whlch musL be
made up with funds from the states revenue base. lL ls anLlclpaLed LhaL sLaLes wlll agaln see a
reducLlon ln lMA raLes as flscal problems conLlnue Lo plague Lhe federal governmenL. 1hls poslLlon
ls also backed wlLh evldence LhaL shows decllnlng lMA raLes over pasL years, desplLe economlc
condlLlons.

77
unlLed SLaLes AsslsLanL SecreLary for lannlng and LvaluaLlon (ASL) and unlLed SLaLes ueparLmenL of PealLh and Puman Servlces
lederal Medlcald AsslsLance ercenLages or lederal llnanclal arLlclpaLlon ln SLaLe AsslsLance LxpendlLures lMA, Accessed aL
hLLp://aspe.hhs.gov/healLh/fmap.hLm
78
uurlng Lhe federal debL celllng debaLe ln laLe 2011, Lhe Cbama admlnlsLraLlon lssued a plan Lo cuL $100 bllllon from federal
Medlcald spendlng over Lhe nexL decade by changlng and replaclng Lhe LradlLlonal lederal Medlcal AsslsLance ercenLages (lMA)
(and oLher fundlng formulas) Lo Lhe sLaLes LhaL deLermlne how many federal dollars sLaLes geL for Medlcald lnLo a "blended raLe"
LhaL would slmpllfy Lhe way federal money ls dlvvled among Lhe sLaLes. 1he blended-raLe proposal would replace Lhls mlx of
maLchlng raLes wlLh a slngle (blended) maLchlng raLe for each sLaLe, whlch would apparenLly apply Lo all of a states Medicaid and
CPl expendlLures, ouLslde of admlnlsLraLlve cosLs. 1hls new formula would shlfL a greaLer share of Medlcald spendlng Lo Lhe
sLaLes. 1he blended raLe would be seL slgnlflcanLly below Lhe comblned effecL of Lhe varlous federal maLchlng raLes a sLaLe would
oLherwlse recelve (ln essence a cuL). 1he Cbama AdmlnlsLraLlon esLlmaLed LhaL Lhls package of changes would save $14.9 bllllon
over 10 years sLarLlng ln 2017. 1he federal governmenL would pay a lower percenLage of overall Medlcald and Chlldrens PealLh
lnsurance rogram (CPl) cosLs Lhan under currenL law, and sLaLes would bear a greaLer share. AlLhough Lhls proposal ls sald Lo
have been tabled for further study, the concept caught the attention of federal deficit reducers and could be dusted off for
use ln Lhe near fuLure. CerLaln pollcymakers also belleve LhaL reducLlons ln federal maLchlng asslsLance wlll deLer expanslons Lo
healLh care access. PealLh Affalrs: PealLh ollcy 8rlef, !anuary 12, 2012.
CalculaLlons done uslng Lhe blended raLe formula as early as a year ago, had Lhe SLaLe of Malne loslng close Lo $700 mllllon dollars
beLween 2014 and 2022 from pro[ecLed spendlng under Lhe ACA lMA formula. urew Conshorowskl, Medlcald Lxpanslon Wlll
8ecome More CosLly Lo SLaLes, netltoqe lssue 8rlef no. 3709. AugusL 30, 2012.
ln Malne, lMA raLes have decllned slnce
2000. Lach percenLage-polnL drop ln Lhe
lMA raLe resulLs ln approxlmaLely $23
mllllon ln reduced federal parLlclpaLlon,
whlch musL be made up wlLh funds from Lhe
states revenue base.
age: 42
I|gure 23 shows Lhe Lrend llne of lMA, SCPl lMA, and A88A lMA. SCPl lMA ls Lhe SLaLe
Childrens Health Insurance Program, and raLes are seL under 1lLle xxl for cerLaln chlldren of
expendlLures for medlcal asslsLance descrlbed ln porLlons of Lhe Soclal SecurlLy AcL. 1he raLe ls an
enhanced raLe esLabllshed Lhrough a formula esLabllshed ln SecLlon 2103(b) of Lhe Soclal SecurlLy
acL and ls calculaLed based upon Lhe sLaLes base raLe and a percenL dlfference beLween LhaL number
and one hundred. Powever, no sLaLe may have a raLe LhaL exceeds elghLy-flve percenL. 1he A88A
lMA was Lemporary addlLlonal fundlng from Lhe Amerlcan 8ecovery and 8elnvesLmenL AcL of 2009
Lo help sLaLes wlLh revenue shorLfalls and lncreased caseload due Lo Lhe 2007-Lo-2009 recesslon.
Lach sLaLe quallfled for Lhe lMA lncreases based upon Lhree separaLe areas: a hold-harmless
amounL, a seL 6.2 lncrease, and an lncrease relaLed Lo unemploymenL.
79

Ma|ne l|vate lea|t| lnsuance lem|um logam (llll)
SLaLes have pursued a number of sLraLegles Lo leverage fundlng and sLreLch Lhelr healLh-care dollars
ln order Lo avold cuLLlng ellglblllLy for famllles. AuLhorlzed under SecLlon 1906 of Lhe Soclal SecurlLy
AcL, PealLh lnsurance remlum aymenL (Pl) programs subsldlze enrollmenL ln employer-
sponsored prlvaLe healLh lnsurance for Medlcald-ellglble lndlvldualsand Lhelr famllleswho have
access Lo such coverage and for whom lL ls cosL-effecLlve.

79
See A88A - Medlcald lMA lncrease rovlslons available from the National Conference of State Legislatures, accessed at:
hLLp://www.ncsl.org/prlnL/sLaLefed/A88A-MedlcaldlMAlncreaserovlslons.pdf.
60
62
64
66
68
70
72
74
76
78
80
1
9
8
S
1
9
8
6
1
9
8
7
1
9
8
8
1
9
8
9
1
9
9
0
1
9
9
1
1
9
9
2
1
9
9
3
1
9
9
4
1
9
9
S
1
9
9
6
1
9
9
7
1
9
9
8
1
9
9
9
2
0
0
0
2
0
0
1
2
0
0
2
2
0
0
3
2
0
0
4
2
0
0
S
2
0
0
6
2
0
0
7
2
0
0
8
2
0
0
9
2
0
1
0
2
0
1
1
2
0
1
2
2
0
1
3
2
0
1
4
Iedera| I|sca| ear
Ma|ne IMA n|story
kegu|ar IMA
SCnI IMA
A88A Lnhanced lMA
"#$%&' 8=) @S' [#6.+&G +7 "0U* #3 01#3'
age: 43
PHIP is Maines premium assistance
program creaLed ln 1993. (See I|gure 24.)
Powever, unllke 8hode lsland, lowa, and
ennsylvanla programs, Lhe Malne Pl
program has shown low enrollmenL and
mlnlmal cosL-savlngs. lowa has hlghllghLed
Pl as an essenLlal sLraLegy for Medlcald
expanslon under Lhe Affordable Care AcL
(ACA) Lo boLh reduce cosLs per member and malnLaln provlder capaclLy. 1he Lhree sLaLes program
deslgns dlffer from Malne Pl as follows:
LnrollmenL ls mandaLed ln Lhe oLher sLaLes. 8hode lsland, ln parLlcular, began wlLh low
enrollmenL under a volunLary program buL was able Lo reach more Lhan 6 of cases when
enrollmenL ln Pl was mandaLed. MalneCare requlres members Lo conLacL Lhe Pl
admlnlsLraLor ln order Lo be enrolled. 8hode lsland also passed leglslaLlon Lo requlre
Medlcald rovlders Lo submlL lnformaLlon on employer-sponsored healLh lnsurance (LSl) as
a condlLlon for enrollmenL. ln addlLlon, all oLher employers were requlred Lo submlL Llmely
flllngs on LSl (8lCL 40-6-9.1).
CosL effecLlveness ls deLermlned on an employer-by-employer basls. Cnce deLermlned,
famllles are noLlfled by mall LhaL Lhey have been enrolled ln Pl.
AdmlnlsLraLors concenLraLe enrollmenL on famllles raLher Lhan ellglble chlldren. 1hls may
become more lmporLanL for Malne slnce parenL-lncome ellglblllLy has dropped below LhaL
of chlldren.
ln|t|a| lssues w|t| ua||ty
ln Sect|on II of Lhls reporL, a number of quallLy lssues wlLh Medlcald ln
general were hlghllghLed. 1he process of evaluating Maines
performance measures ls ongolng, however, a number of
performance measures have been examlned ln several areas.
ConslsLenL wlLh naLlonal sLudles, Lwo areas LhaL surfaced lmmedlaLely
wlLhln MalneCare were readmlsslon raLes and walLllsLs for walver
servlces. 8oLh lssues Lend Lo have slmllar demographlcs, Lhey boLh
Lend Lo be older adulLs wlLh mulLlple chronlc condlLlons whose care ls uncoordlnaLed.
Malne readmlsslon raLes wlLhln 30 days for persons ln many areas exceeded Lhe naLlonal average.
(See I|gure 2S.) 8eadmlsslon ls deflned as a secondary admlsslon for Lhe same admlLLlng dlagnosls
wlLhln a LhlrLy day perlod.
80
MalneCare has aLLempLed Lo curb Lhese Lrends Lhrough an exlsLlng

80
MalneCare 8edeslgn 1ask lorce 8ecommendaLlon 8eporL, uecember 2012.
State rogram Start
ercent of Iam|||es
Lnro||ed |n nI
Malne 1993 Less Lhan 1 percenL
8hode lsland 2001 6
lowa 1991 1.6
ennsylvanla 1994 1.9
Med|ca|d nea|th Insurance rem|um rograms (nI)
"#$%&' 8?) *'&-'3. +7 "15#4#'6 23&+44'/ #3 [X**
1wo areas LhaL surfaced
lmmedlaLely for walver
servlces are:
1. 8eadmlsslon raLes
2. WalLllsLs
age: 44
Ma|ne
kate
U.S.
kate
regnancy, ChlldblrLh 7.0 3.8
MenLal PealLh 21.3 11.8
ClrculaLory 21.3 10.4
8esplraLory 22.4 11.4
ulgesLlve 22.6 10.3
Alcohol/urug use 21.1 13.0
MusculoskeleLal 10.8 8.3
nervous 17.1 9.3
Llver, ancreas 23.3 12.3
MeLabollc 20.2 10.7
Skln, 8reasL 17.4 8.0
lnfecLlons 27.4 11.3
kldney 23.9 12.4
ln[urles, olsonlngs 16.8 8.4
PealLh SLaLus 18.6 9.9
lemale 8eproducLlve 6.4 6.4
Lar, nose, MouLh & 1hroaL 12.6 7.2
MyeloprollferaLlve ulseases 49.7 37.4
8lood 36.4 14.1
Male 8eproducLlve 12.8 7.2
Plv lnfecLlons 24.4 17.2
MulLlple 1rauma 10.3 7.9
Lye 40.9 6.9
8urns 3.9 6.1
1C1AL 17.7 9.4
nosp|ta| keadm|ss|ons w|th|n 30 days
Source: 1able 16 (Malne PosplLal 8eadmlsslons wlLhln 30
days), Moloecote keJeslqo 1osk lotce kecommeoJotloo
kepott , uecember 2012, pp. 26-27.
pollcy. CurrenLly MalneCare does noL relmburse for readmlsslon wlLhln 72 hours and ln 2012
presenLed recommendaLlons Lo exLend Lhls perlod.
81

ln addlLlon Lo hlgh readmlsslon raLes, Lhere ls
Lhe lssue of Lhe large walLlng llsLs Lo geL lnLo
speclflc programs wlLhln MalneCare. 1o be
clear, Lhese walLlng llsLs are persons who are
already members of MalneCare buL are walLlng
for servlces more approprlaLe Lo Lhelr needs. As
of SepLember 2013, MalneCare had walLlng llsLs
for Lhese servlces of approxlmaLely 3,100
members, accordlng Lo Lhe Cfflce of Aglng and
ulsablllLy Servlces (CAuS). 1hese lndlvlduals are
ofLen some of Lhe mosL vulnerable clLlzens and
lnclude Lhe elderly, lndlvlduals wlLh dlsablllLles,
and persons wlLh developmenL dlsablllLles.
1hese clLlzens have experlenced walL Llmes of
over Lwo years ln some cases ln order Lo be
placed for servlces LhaL lnclude sLaLe-funded
home based care, assessmenL, and
homemakers servlces.
1hey are generally low-
lncome famllles who have
no oLher alLernaLlve for
medlcal and behavloral-
healLh servlces and for
whlch resources wlll llkely
be unavallable when ACA
expanslon ls adopLed. CompllcaLlng Lhe maLLer
of Lhe walLllsLs are Lhe numerous number of
programs operaLed ln order Lo effecLlvely
provlde servlce Lo Malners. Malne currenLly has
elghL of Lhese programs wlLh walLllsLs.

81
ldem.

"#$%&' 8H) 01#3' C'1/5#66#+3 C1.'6 LG 0'/#-14 U&'1

Malne currenLly
has elghL
programs wlLh
walLllsLs for Lhe
mosL vulnerable
populaLlons.
age: 43
I|gure 26
82
hlghllghLs boLh walver servlces for lndlvlduals wlLh lnLellecLual dlsablllLles, physlcal
dlsablllLles and braln ln[urles along wlLh sLaLe-only home-based servlces, Lhe number of persons
awalLlng servlces, and Lhe average cosLs Lo operaLe Lhese programs. 1he charL lndlcaLes LoLal
walLllsLs for all programs Lo be sllghLly more Lhan 3,900. 1hls number ls larger Lhan Lhe acLual walLllsL
LoLal of 3,100 due Lo Lhe allowance for enrollmenL ln more Lhan one program. All programs llsLed
offer a range of servlces LhaL lnclude personal asslsLance ln Lhe home wlLh acLlvlLles for dally llvlng
such as baLhlng, dresslng, meal preparaLlon, and baslc housekeeplng. AddlLlonal servlces lnclude
lnpaLlenL cosLs aL nurslng faclllLles and oLher resldenLlal care servlces.

82
Mary Mahew, 1he MalneCare rogram 8lghL Slze, 8lghL Servlce, 8lghL rlorlLles, Table comes from MuPPS presenLaLlon, lall
2013, sllde 19.
"#$%&' 8N) K.1.' 13/ 01#3'I1&' *&+$&15 F1#.4#6.6
age: 46
Musk|e Schoo| Lst|mates of Average Age of Long-1erm Care Users by Sett|ng for SI 2010
83

1he number of MalneCare members uslng long-Lerm care servlces ls a slgnlflcanL cosL facLor LhaL
needs Lo be consldered. 1he bar charL was publlshed by Lhe Muskle School of ubllc Servlce and
I|gure 27 deplcLs Lhe average age of long-Lerm care uses by seLLlng for Sl? 2010.
A worsenlng economy, an aglng workforce and
populaLlon, rlslng cosLs ln healLh care, and
lncreases ln poverLy levels wlll wlLhouL doubL
lncrease uLlllzaLlon of currenL MalneCare
servlces.
I|gure 28 shows Lhe varlous caLegorles quallfylng for MalneCare. 1hese caLegorles fall lnLo one of
two groups: traditional Medicaid and other. Categories under traditional Medicaid are mostly
groups that states are mandated to cover to qualify for FMAP funding. Categories under other
Medlcald groups are opLlonal groups resulLlng from cholces made by Lhe sLaLe. 1he Lable shows per
member per monLh (MM) cosLs for each MalneCare caLegory.

83
Muskle School CharLbook, llgure 3-1, p. 18.
"#$%&' 8R) U$' LG B@I "1-#4#.G K.1.#6.#-6
A worsenlng economy, an aglng workforce
and populaLlon, rlslng cosLs ln healLh care,
and lncreases ln poverLy levels wlll wlLhouL
doubL lncrease Lhe uLlllzaLlon of currenL
MalneCare servlces.

age: 47
lo||cy C|anges on t|e bn|nsueo ano bncomoensateo Cae
Slnce 1998, Malne has adopLed a number of pollcles ln an aLLempL Lo reduce Lhe number of people
wlLhouL healLh lnsurance and curb uncompensaLed care cosLs.
84
ln
2002, Malne applled for and recelved a SecLlon 1113(a)
demonsLraLlon walver LhaL allowed chlldless adulLs wlLh lncome aL
or below 100 of lL Lo recelve a comprehenslve beneflL package.
1he CenLers for Medlcare and Medlcald (CMS) allowed Lhe sLaLe Lo
Lap unused dlsproporLlonaLe share hosplLal (uSP) alloLmenLs Lo
make up Lhe federal share of lLs walver. revlously, a porLlon Lhe
uSP allocaLlon had been dlvlded up among psychlaLrlc hosplLals and
communlLy hosplLals, nelLher of whlch LradlLlonally meL Lhelr uSP
llmlL. 1he uSP allocaLlon, currenLly aL $83 mllllon (sLaLe and federal) became Lhe upper llmlL for Lhe
program. ln Lhe walver proposal, Lhe sLaLe esLlmaLed LhaL 11,000 new members would enroll ln Lhe

84
The American Hospital Association defines uncompensated care as follows: Uncompensated care is an overall measure of
hosplLal care provlded for whlch no payment was received from the patient or insurer. It is the sum of a hospital's bad debt and
Lhe charlLy care lL provldes. CharlLy care ls care for whlch hosplLals never expecLed Lo be relmbursed. A hosplLal lncurs bad debL
when lL cannoL obLaln relmbursemenL for care provlded, Lhls happens when paLlenLs are unable Lo pay Lhelr bllls, buL do noL
apply for charlLy care, or are unwllllng Lo pay Lhelr bllls. uncompensaLed care excludes oLher unfunded cosLs of care, such as
underpaymenL from Medlcald and Medlcare. Hospital Care Cost, Ametlcoo nospltol Assoclotloo loct 5beet oo uocompeosoteJ
cote, uecember 2010.
"#$%&' 8V) 01#3'I1&' 23&+445'3.@+.14 0'5L'&6 13/ *0*0

Lven wlLh expanslons of
publlc programs over Lhe
years, Maines percentage
of unlnsured resldenLs
under age 63 has
remalned falrly consLanL
on an annual basls.
Members MM Members MM
1rad|t|ona| Ma|neCare
Aged 22,932 $1,472 22,778 $1,327
8llnd or ulsabled 31,806 $1,379 32,013 $1,333
Chlldren <100 lL 110,732 $312 107,312 $321
arenLs <100 lL 30,494 $392 48,848 $392
regnancy 1,893 $887 1,922 $912
SLaLe Cnly 1,689 $2,226 767 $1,786
CLher 1radlLlonal 10,889 $267 12,734 $234
1ota| 1rad|t|ona| Ma|neCare 2S0,438 5711 246,397 5712
Cther Groups
Chlldless AdulL Walver 16,086 $438 10,689 $314
Chlldren > 100 lL 16,363 $214 14,178 $222
arenLs (100-130 lL) 22,137 $280 19,702 $271
1ota| Cther S4,607 5312 44,S69 5314
Grand 1ota|s 30S,04S 5639 290,96S 56S1
Ma|neCare Lnro||ment and er Member er Month (MM) Costs
Category
SI 2011-12 SI 2012-13
age: 48
flrsL year. Powever, by CcLober 2003, fourLeen monLhs afLer lmplemenLaLlon 16,834 newly
ellglble chlldless adulLs had enrolled ln MalneCare.
uue Lo Lhe subsequenL SLaLe budgeL shorLfalls and Lhe rlsk of exceedlng Lhe walver cosL neuLrallLy
Lerms, Malne requesLed Lo amend Lhe walver by reduclng Lhe currenL demonsLraLlon beneflL
package and ellmlnaLlng reLroacLlve coverage for demonsLraLlon populaLlons. 1hese amendmenLs
were approved on SepLember 6, 2003 shorLly afLer enrollmenL was Lemporarlly capped.
SubsequenLly, enrollmenL caps were used Lo conLrol spendlng and by 2013, Lhe cap reduced Lhe
programs spending to approximately $50 million in combined annual federal and state spending.
As of SepLember 2013, Lhere were less Lhan 8,300 enrolled chlldless adulLs. 1he walver Lo cover
Lhese lndlvlduals wlll explre on uecember 31, 2013.
83

Whlle Lhese pollcles dld resulL ln small and Lemporary decreases ln Lhe number of unlnsured clLlzens,
lL proved noL Lo be a long-Lerm soluLlon ln reduclng Lhe number of unlnsured clLlzens, whlch has
remalned falrly consLanL on an annual basls as a percenLage of all lndlvlduals under 63 years of age,
as can be seen ln I|gure 29. Cver Lhe same perlod of Llme, from Sl? 1999-2000 Lo Sl? 2012-13, Lhe
LoLal MalneCare budgeL, lncludlng boLh sLaLe and federal funds, rose from $1.2 bllllon Lo almosL $2.3
bllllon, an lncrease of 109. ln Lerms of sLaLe funds, Lhe lncrease was even greaLer. lL grew from
$403 mllllon Lo $992 mllllon, an lncrease of 146.
Maines experience in expanding eligibility for MaineCare did not result in a noticeable reduction in
uncompensaLed care. LaLesL esLlmaLes by Lhe Malne PosplLal AssoclaLlon place charlLy care aL
approxlmaLely $200 mllllon. !usL llke enrollmenL and Lhe MalneCare budgeL, hosplLal charlLy care
also exceeded budgeL LargeLs as lL grew by more Lhan 200 from 2000 Lo 2013. As Lhese numbers
clearly lndlcaLe, desplLe efforLs Lo expand healLh coverage ln order Lo reduce Lhe number of
unlnsured clLlzens and curb uncompensaLed care, boLh lssues remaln unsolved.
1hls lack of evldence llnklng Medlcald ellglblllLy expanslons wlLh reducLlons ln uncompensaLed care
cosLs may be explalned by Lhe resulLs of several sLudles, lncludlng one by !onaLhan Cruber and
Slmon kosall, (2007).
86

83
CenLer for Medlcare and Medlcald Servlces, Walver lnformaLlon, accessed aL hLLp://www.medlcald.gov/Medlcald-CPl-rogram-
lnformaLlon/8y-1oplcs/Walvers/1113/downloads/me/me-chlldless-adulLs-fs.pdf.
86
!onaLhan Cruber and Slmon Kosali. Crowd-CuL 1en ?ears LaLer: Pave 8ecenL ubllc lnsurance Lxpanslons Crowded CuL rlvaLe
Health Insurance? National Bureau Economic Research, January 2007. The continued interest in public insurance expansions as
a means of coverlng Lhe unlnsured hlghllghLs Lhe lmporLance of esLlmaLes of "crowd-ouL", or Lhe exLenL Lo whlch such expanslons
reduce prlvaLe lnsurance coverage. 1en years ago, CuLler and Cruber (1996) suggesLed LhaL such crowd-ouL mlghL be qulLe large,
2003 2004 200S 2006 2007 2008 2009 2010 2011
12 10 12 11 10 12 12 11 11
u5 ceosos 8oteoo
Ma|ne Insurance Coverage for Ind|v|dua|s under 6S ears C|d
ercent Un|nsured
"#$%&' 8W) 01#3' J3#36%&'/ C1.'6
age: 49
As Lhe sLudy found:
continued interest in public insurance expansions as a means of covering the
oolosoteJ highlights the importance of estimates of crowd-out, or the extent to
wblcb socb expoosloos teJoce ptlvote losotooce covetoqe. Oot tesolts cleotly sbow
tbot ctowJ-oot ls slqolflcoot, tbe ceottol teoJeocy lo oot tesolts ls o ctowJ-oot tote
of about 60%.
8ecenL evldence from employer-sponsored lnsurance (LSl) ln Malne would supporL LhaL research.
lrom 2000 Lo 2011, LSl coverage ln Malne for Lhe under-63 populaLlon fell from 69.6 Lo 61.3.
87

buL much subsequenL research has quesLloned Lhls concluslon. We revlslL Lhls lssue by uslng lmproved daLa and lncorporaLlng
Lhe research approaches LhaL have led Lo varylng esLlmaLes. We focus ln parLlcular on Lhe publlc lnsurance expanslons of Lhe
19962002 perlod. Cur resulLs clearly show LhaL crowd-ouL ls slgnlflcanL, Lhe cenLral Lendency ln our resulLs ls a crowd-ouL raLe
of abouL 60.
87
Elise Gould, Employer-Sponsored PealLh lnsurance Coverage ConLlnues Lo uecllne ln a new uecade., ll 8tlefloq lopet #J5J,
Lconomlc ollcy lnsLlLuLe, uecember 3, 2012.
age: 30


Sect|on V: kesu|ts of the I|nanc|a| Mode|
age: 31
Sect|on v: 8esu|ts o t|e l|nanc|a| Mooe|
Cvev|ew o l|nanc|a| Mooe|
1he Alexander Croup developed and cusLomlzed a flnanclal model Lo forecasL enrollmenL and Lhe
assoclaLed flscal cosLs of MalneCare. varlous scenarlos assumlng currenL Lrends were run Lo help
Malne pollcymakers undersLand poLenLlal cosLs lf Malne were Lo declde Lo expand ellglblllLy for
MalneCare pursuanL Lo Lhe ACA LhaL Lhe u.S. Supreme CourL ruled ls opLlonal for Lhe sLaLes.
1he flrsL sLep ln any flnanclal model ls Lo esLabllsh a basellne, wlLhouL whlch Lhere would be no basls
for knowlng whaL Lhe addlLlonal cosL of a proposal would be. ln Lhls case, AC creaLed Lwo basellnes
Lo help pollcymakers undersLand how Lwo posslble program Lrends wlll llkely Lrack. 1he second sLep
ls Lo lncorporaLe changes Lo Lhe basellnes Lo lnclude a LesL case, l.e., a proposal belng consldered.
1he Lhlrd sLep ls Lo compare Lhe scenarlos and evaluaLe Lhe dlfferences beLween Lhe LesL case and
Lhe basellnes.
lor Lhls analysls, Lhe LesL case belng evaluaLed ls LhaL Malne would expand ellglblllLy of MalneCare
Lo allow enrollmenL of all lndlvlduals deLermlned Lo have lncome equal Lo or less Lhan 138 of lL.
1hls LesL case ls called Lhe expanslon scenarlo. 1he flnanclal model assumes an effecLlve daLe of !uly
1, 2014, for lmplemenLaLlon of Lhe expanslon.
1here are Lwo basellnes ln Lhls analysls: 8ase||ne 1 and 8ase||ne 2.
8ase||ne 1 ls a forecasL of how Lhe MalneCare wlll Lrack ln Lhe
fuLure wlLhouL expanslon and assumlng pendlng changes Lo
MalneCare as approved by Lhe CenLers for Medlcare and
Medlcald Servlces (CMS) of uSuPPS. AlLhough MalneCare
allowed enrollmenL of parenLs up Lhrough 138 of lL,
beglnnlng on !anuary 1, 2014, MalneCare wlll only allow
enrollmenL up Lo 100 of lL. Also beglnnlng on !anuary 1,
2014, Lhe Chlldless AdulLs Walver wlll explre. AlLhough Lhls
walver allowed coverage for chlldless adulLs up Lo 100 of lL,
and as explalned earller ln Lhls reporL, enrollmenL ln Lhe walver
was capped for budgeLary reasons.
8ase||ne 2 ls Lhe same as 8ase||ne 1, excepL for one ma[or dlfference. 8ase||ne 2 assumes LhaL
MalneCare coverage for parenLs from 101 Lo 138 of lL wlll noL be dlsconLlnued.
1he basellne and Lhe LesL case scenarlos presenLed ln Lhls secLlon are based on currenL-Lrend
analysls LhaL assumes Lhe deLermlnlng facLors wlll conLlnue Lhelr currenL Lra[ecLory, l.e., Lhe values
8ase||ne Assumpt|ons
8ase||ne 1 assumes Lwo
programs wlll be
dlsconLlnued: (1) parenLs
101 Lo 138 of lL, and (2)
Lhe Chlldless AdulL Walver.
8ase||ne 2 assumes only Lhe
Chlldless AdulL Walver wlll be
dlsconLlnued.
age: 32
chosen for Lhese facLors are ln Lhe mlddle of a posslble range of opLlons. As wlLh all forecasLs, Lhere
are rlsks LhaL Lhese scenarlos wlll noL be reallzed and Lhe acLual paLh Laken wlll vary above or below
Lhe forecasL. 1hese posslblllLles wlll be dealL wlLh ln Sect|on VI on rlsk analysls. More Lechnlcal
lnformaLlon on meLhodology, key assumpLlons, and daLa sources are found ln Append|x 8.
loou|at|on
1he flnanclal model resLrlcLed lLs analysls Lo Lhose lndlvlduals enrolled ln MalneCare wlLh full
beneflLs. ln oLher words, oLher persons wlLh parLlal beneflLs were excluded.
88

1he AC llnanclal Model uLlllzes sLandard acLuarlal analysls (See I|gure 30) Lo predlcL poLenLlal
growLh ln Lhe basellne scenarlos. An lmporLanL facLor used ln Lhe analysls ls Lhe poverLy raLe.
8ecause Malne has had a slgnlflcanL lncrease ln lLs poverLy raLe, lL lmpacLs Lhe forecasL on Lhe
number of lndlvlduals who wlll become ellglble for MalneCare.

88
Low-lncome Medlcare buy-ln groups who meeL Lhe crlLerla for parLlclpaLlon ln urugs for Llderly (uLL) program and/ or Malne 8x
were excluded ln Lhe forecasL.
"#$%&' =A) U33%14 UP'&1$' *&+,'-.'/ >&+E.S C1.'6
Age Group overty 1ota| opu|at|on
under 18 0.0308 -0.0131
18-64 0.0248 0.0046
63 and Cver 0.0361 0.0136
1oLal 0.0278 0.0024
Annua| Average ro[ected Growth kates
8ased on Actuar|a| Ana|ys|s
age: 33
1he graph ln I|gure 31 shows Lhe esLlmaLed growLh ln poverLy based on hlsLorlcal Lrends and
acLuarlal assumpLlons. 1he acLuarlal assumpLlons used for Lhese scenarlos are mlddle values, LhaL
ls, Lhe acLual growLh could be somewhaL hlgher or lower Lhan pro[ecLed. 1he rlsks of hlgher or lower
growLh are dlscussed ln Sect|on VI of Lhls reporL. lmporLanLly, Lhe growLh ln poverLy wlll lmpacL boLh
Lhe basellne scenarlo as well as Lhe expanslon scenarlo.
8ecause of Lhe hlgh poverLy growLh, Lhe flnanclal model predlcLs a slgnlflcanL growLh ln Lhe basellne
scenarlos, whlch can be seen ln I|gure 32. 1hus, even wlLhouL expandlng ellglblllLy, MalneCare
enrollmenL ls pro[ecLed Lo grow by an annual average of 2.8 for boLh basellnes. 1hls may noL seem
Lo be Lremendous growLh, and lL ls noL over one or Lwo years. Powever, growLh raLes when
susLalned compound and grow exponenLlally. 1herefore, a 2.8 annual growLh raLe over nlne years
ls a LoLal lncrease of nearly 29, whlch would add 79,377 persons Lo Lhe enrollmenL of 276,231 ln
Sl? 2023-24 for 8asellne 1 or 83,493 persons Lo Lhe enrollmenL of 292,936 ln Sl? 2023-24 for
8asellne 2.
AlLhough Lhere ls only one ma[or dlfference beLween Lhe basellnes, Lhe lmpacL on enrollmenL and
flscal cosLs ls slgnlflcanL. I|gure 33 shows Lhe dlfference ln populaLlon beLween Lhe Lwo basellnes.
LnrollmenL for parenLs beLween 101 and 138 of lL would grow from 16,683 ln Sl? 2014-13 Lo
20,801 ln Sl? 2023-24.

"#$%&' =() 01#3' U-.%1&#14 "+&'-16. +7 *'&6+36 #3 *+P'&.G
124,727
169,076
186,484
24S,317
36,S40
48,734
S1,386
69,S97
0
S0,000
100,000
1S0,000
200,000
2S0,000
2000 200S 2010 201S 2020
Actuar|a| Iorecast of ersons |n overty
Census 8ureau opu|at|on
Lst|mates for 2012
Decenn|a| Census Counts
Actuar|a| Iorecast
age: 34

"#$%&' =8) ;16'4#3' 23&+445'3. "+&'-16.6
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1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
State I|sca| ear
opu|at|on D|fference between 8ase||nes
"#$%&' ==) 23&+445'3. <#77'&'3-'6 L'.E''3 ;16'4#3'6
age: 33
under Lhe expanslon scenarlo, Lhe populaLlon wlll grow more dramaLlcally. 1he average annual
growLh becomes 3.3 over Len years, whlch would be a LoLal lncrease of 71.3. 1hls would add
200,373 persons onLo Lhe rolls, lncludlng Lhe enrollmenL growLh for Lhe basellnes, l.e., 79,377
persons added under 8asellne 1 or Lhe 83,493 persons added under 8asellne 2. Powever, Lhe
average annual growLh raLe can be mlsleadlng because Lhere wlll lnlLlally be a large lncrease ln Sl?
2014-13.
89
AfLer Sl? 2014-13, Lhe average annual growLh raLe ls pro[ecLed Lo be 2.8. (See I|gure
34.)
lor Lhls analysls, Lhe followlng populaLlon groups were assumed Lo be added Lo MalneCare: chlldless
adulLs up Lhrough 138 of lL, parenLs beLween 101 and 138 of lL (whlch ls assumed ln
8asellne 2 buL noL ln 8asellne 1), persons aL 138 of lL or below currenLly enrolled ln prlvaLe
lnsurance who would lose Lhelr coverage, lncludlng chlldren up Lhrough 200 of lL, parenLs aL
100 or below lL currenLly ellglble for MalneCare
buL who wlll enroll because of Lhe so-called
woodwork effect; and children at 200% of FPL or
below who will enroll because of the woodwork
effect.
I|gure 3S glves Lhe esLlmaLed number of new

89
lL may Lake some Llme before Lhe lnlLlal lncrease ln enrollmenL wlll be accompllshed, whlch may carry over lnLo Lhe succeedlng
flscal year. 1o keep Lhe model from becomlng Loo compllcaLed, lL was assumed all of Lhe lnlLlal lncrease would lncur ln Lhe flrsL
year.
Lxperlence has shown LhaL whenever
Medlcald enrollmenL ls expanded, people
who are already ellglble also enroll. 1hls
is called the woodwork effect.
3
1
1
,
2
4
2

3
0
6
,
7
S
2

2
8
1
,
1
4
7

3
7
6
,
8
7
0

3
8
7
,
2
2
3

3
9
7
,
8
7
3

4
0
8
,
8
3
0

4
2
0
,
1
0
2

4
3
1
,
6
9
9

4
4
3
,
6
2
9

4
S
S
,
9
0
3

4
6
8
,
S
3
0

4
8
1
,
S
2
0

-
100,000
200,000
300,000
400,000
S00,000
2
0
1
1
-
1
2
2
0
1
2
-
1
3
2
0
1
3
-
1
4
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
State I|sca| ear
kev|sed opu|at|on w|th Lxpans|on
"#$%&' =?) 01#3'I1&' 23&+445'3. E#.S 29:136#+3
age: 36
persons from Lhose caLegorles who wlll llkely enroll ln MalneCare. 1he LoLal lnlLlal enrollmenL ls
esLlmaLed Lo be 100,620 wlLhln Lhe flrsL program year, assumlng full lmplemenLaLlon.
90

1he caLegory of persons loslng prlvaLe coverage requlres some explanaLlon. 1here are Lwo
subgroups wlLhln Lhls caLegory. llrsL, Lhere are lndlvlduals wlLh non-group coverage. 1he ACA has
made many of Lhese more affordable healLh care plans lllegal, and many lnsurers have recenLly senL
cancellaLlon noLlces Lo holders of Lhese pollcles. 8ecause of federal requlremenLs LhaL plans musL
lnclude all federally-deflned essenLlal healLh beneflLs and oLher regulaLlons, such as communlLy
raLlng requlremenLs, replacemenL pollcles are slgnlflcanLly more expenslve. 1haL wlll llkely make Lhe
cosLs of Lhe new pollcles unaffordable for
Lhese lndlvlduals. lf ellglblllLy for Medlcald
were expanded, a number of Lhese lndlvlduals
would quallfy and llkely come onLo Lhe
MalneCare rolls. 1he second subgroup ls
comprlsed of Lhose lndlvlduals wlLh employer-
provlded coverage. 1here ls evldence Lhrough
sclenLlflc surveys as well as anecdoLal evldence
LhaL some employers plan Lo drop coverage,
91

and Lhose employers LhaL declde agalnsL
dropplng coverage can effecLlvely maneuver Lo
do Lhe same for Lhelr low-lncome employees.
1hose employers wlLh less Lhan flfLy employers are noL sub[ecL Lo any federal penalLles lf Lhey do
not offer insurance. From a small business firms point of view, it makes flnanclal sense Lo allow Lhe
governmenL Lo pay for employee healLh coverage Lhan for Lhe flrm Lo lncur LhaL cosL. Some of Lhese
smaller employers, Lherefore, wlll llkely drop coverage. lor larger employers, Lhere are penalLles ln
Lhe law lf Lhey do noL provlde healLh lnsurance Lo Lhelr employees, buL lL may noL be necessary for
Lhem Lo drop coverage and susLaln Lhe penalLles ln order for Lhem Lo encourage Lhelr low-lncome
employees Lo enroll ln Medlcald. 1hese employers can slmply choose plans wlLh premlum cosL
sharlng aL hlgh enough levels LhaL make lL flnanclally conduclve for Lhelr low-lncome employees Lo
enroll ln Medlcald. 1hls LacLlc also could be used by smaller employers as well.
1he lasL Lwo caLegorles of Lhe expanslon populaLlon ln I|gure 3S deserve furLher explanaLlon.
Lxperlence has shown LhaL whenever Medlcald enrollmenL ls expanded, people who are already
ellglble also enroll. So, ln addlLlon Lo new caLegorles LhaL expand Lhe enrolled populaLlon, Lhere ls
also an lncrease ln esLabllshed programs. 1hls phenomenon has been crudely called the woodwork
effect. It comes from the expression that they come out of the woodwork, because Medicaid

90
ldem.
91
Shubham Singhai, Jeris Stueland, and Drew Ungerman, How US health care reform will affect employee benefits, Mcklosey
Ooottetly, !une 2012, accessed aL:
hLLp://www.mcklnsey.com/lnslghLs/healLh_sysLems_and_servlces/how_us_healLh_care_reform_wlll_affecL_employee_beneflLs
"#$%&' =H) 01#3'I1&' 23&+445'3. K"Z 8A(?Q(H 29:136#+3
"+&'-16.
Lxpans|on Lnro||ment Iorecast
SI 2014-1S
Lst|mate
Chlldless AdulLs up Lo 138 lL 47,313
arenLs beLween 101 -138 lL 16,683
ersons 138 lL and below who
would lose prlvaLe lnsurance
32,678
arenLs 100 lL and 8elow
("woodwork")
1,638
Chlldren ("woodwork") 2,106
1ota| Iorecast 100,620
age: 37
admlnlsLraLors had noL counLed on Lhe lncreased enrollmenL. 1hls phenomenon ls LhoughL posslble
because noL everyone who quallfles for Medlcald slgns up, for whaLever reason he or she mlghL
have for not doing so. Some have suggested that the term woodwork effect has a negative
connotation and have offered the term welcome mat effect as its replacemenL.
I|gure 36 provldes an lllusLraLlon comparlng Lhe basellne forecasLs wlLh Lhe expanslon forecasL of
enrollmenL. 1he dlfference ln Lhe llnes glves Lhe growLh ln enrollmenL due Lo Lhe expanslon.
l|sca| Cost
1he AC llnanclal Model shows LhaL ln Lhese scenarlos Lhe LoLal cosL for Lhe basellnes and expanslon
wlll be slgnlflcanL. lor Lhe 8asellne 1 scenarlo, LoLal cosLs wlll lncrease on average of 3.2 per year,
whlch lncreases Lhe LoLal cosL by 66.7 over a Len-year perlod. 1he average annual growLh raLe,
however, wlll be 3.3 ln Lhe laLLer years. under Lhls scenarlo, Lhe LoLal cosL for MalneCare lncreases
by $1.76 bllllon, from $2.6 bllllon ln Sl? 2013-14 Lo $4.4 bllllon ln Sl? 2023-24. lor 8asellne 2, LoLal
cosLs wlll lncrease on average of 3.3 per year, whlch lncreases Lhe LoLal cosL by 70.2 over a Len-
year perlod. under Lhls scenarlo, Lhe LoLal cosL for MalneCare lncreases by $1.83 bllllon, from $2.6
bllllon ln Sl? 2013-14 Lo $4.3 bllllon ln Sl? 2023-24.
AlLhough Lhe LoLal cosLs beLween Lhe basellne scenarlos may noL seem slgnlflcanLly dlfferenL when
comparlng Lo Lhe overall cosLs, 8asellne 2 cosLs $739 mllllon more over LhaL Len year perlod. I|gure
"#$%&' =N) 01#3'I1&' 23&+445'3. "+&'-16.6 I+5:1&#6+3
3SS,628
281,147
481,S20
376,429
2S0,000
300,000
3S0,000
400,000
4S0,000
S00,000
SS0,000
2
0
1
1
-
1
2
2
0
1
2
-
1
3
2
0
1
3
-
1
4
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
M
a
|
n
e
C
a
r
e

L
n
r
o
|
|
m
e
n
t
State I|sca| ear
Ma|neCare Lnro||ment
1
Iorecast
noLe:
1
lncludes only
enrollees wlLh full beneflLs.
age: 38
37 shows how Lhe dlfference ln LoLal cosLs beLween Lhe Lwo basellnes ls pro[ecLed Lo grow from $38
mllllon ln Sl? 2014-13 Lo $93 mllllon ln Sl? 2023-24.

SLaLe cosLs are also dlfferenL for Lhe Lwo basellnes. 8asellne 2 cosLs $284 mllllon more over Lhe Len
year perlod. I|gure 38 shows how Lhe dlfference ln sLaLe cosLs beLween Lhe Lwo basellnes ls
pro[ecLed Lo grow from $22 mllllon ln Sl? 2014-13 Lo $36 mllllon Sl? 2023-24.
lor Lhe expanslon scenarlo, Lhe LoLal cosL of MalneCare lncreases by $2.7 bllllon ln Sl? 2013-14 Lo
$3.3 bllllon ln Sl? 2023-24, an lncrease of 102. 1he average annual lncrease over Lhose Len years
ls pro[ecLed Lo be 7.3, alLhough ln Lhe laLLer years lL would fall closer Lo 3.3.
1he resulLs of Lhese scenarlos generaLed by Lhe AC llnanclal Model esLlmaLe growLh comparable Lo
Lhe naLlonal average as esLlmaLed by Lhe uSuPPS Cfflce of Lhe AcLuary, dlscussed earller ln Lhls
reporL. AlLhough Malne does noL have Lhe populaLlon growLh of oLher sLaLes, lLs hlgh poverLy growLh
raLe makes up for Lhe dlfference.
The federal government will be absorbing the lions share of the expansion cost in the early years.
Powever, lL would be lncorrecL Lo assume LhaL Malne would noL have any cosLs. CulLe Lo Lhe
conLrary, Lhe cosLs wlll sLlll be slgnlflcanL. 1he ACA provldes 100 relmbursemenL for expendlLures
ln calendar years (C?) 2014 Lhrough 2016 only for new ellglblllLy groups. 8ecause MalneCare has
5
S
8

5
6
1

5
6
4

5
6
7

5
7
1

5
7
S

5
7
9

5
8
3

5
8
8

5
9
3

5-
510
520
530
540
5S0
560
570
580
590
5100
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
M
|
|
|
|
o
n
s
State I|sca| ear
1ota| Cost D|fference between 8ase||nes
1ota| 1en-ear Cost: 5739 M||||on
"#$%&' =R) @+.14 I+6. <#77'&'3-' L'.E''3 ;16'4#3'6
age: 39
allowed more groups Lo become ellglble, Malne would clearly recelve 100 relmbursemenL for
Lhose years for only Lhe chlldless-adulL populaLlon wlLh one posslble excepLlon. AL Lhe Llme LhaL Lhe
ACA became effecLlve, Malne had 10,300 chlldless adulLs enrolled ln lLs Chlldless AdulL Walver
program. 1hese adulLs would llkely recelve a lower lMA, buL MuPPS ls currenLly negoLlaLlng wlLh
CMS ln order Lo recelve Lhe hlgher lMA ln Lhe evenL Lhe sLaLe decldes Lo expand.
5
2
2

5
2
3

5
2
S

5
2
6

5
2
7

5
2
9

5
3
0

5
3
2

5
3
4

5
3
6

5-
5S
510
51S
520
52S
530
53S
540
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
M
|
|
|
|
o
n
s
State I|sca| ear
State Cost D|fference between 8ase||nes
1ota| 1en-ear State Cost: 5284 M||||on
"#$%&' =V) K.1.' I+6. <#77'&'3-' L'.E''3 ;16'4#3'6
age: 60
I|gure 39 lllusLraLes Lhe dlfference ln Lhe LoLal MalneCare cosLs beLween Lhe basellne and expanslon
scenarlos. Lven for Lhose caLegorles LhaL recelve 100 relmbursemenL, Lhe lederal commlLmenL
would decrease beglnnlng ln C? 2017, unLll lL becomes 90 ln C? 2020. 1he expanslon scenarlo
assumes Lhe lederal governmenL wlll conLlnue Lo provlde 90 afLer 2020, buL Lhls assumpLlon ls
noL assured conslderlng Lhe flscal slLuaLlon of Lhe federal governmenL. Clven Lhese assumpLlons,
Lhe AC llnanclal Model predlcLs sLaLe cosLs of $33.4 mllllon ln Sl? 201413, or $47.3 mllllon lf Lhe
hlgher lMA ls denled for Lhe chlldless adulL walver populaLlon when compared Lo Lhe 8asellne 1
scenarlo. (See I|gure 40.)

1he sLaLe cosLs are pro[ecLed Lo
grow Lo $128.1 mllllon ln Sl? 2023
24, for a Len-year LoLal of $832
mllllon, or $863 mllllon lf Lhe hlgher
lMA ls denled.
"#$%&' =W) 01#3'I1&' @+.14 I+6. "+&'-16.
3S.4
33.4
47.0
68.S
78.1
94.6
109.S
11S.4
121.6
128.1
5-
5S0
5100
51S0
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
M
|
|
|
|
o
n
s
State I|sca| ear
Lst|mated State Cost of Lxpans|on over 8ase||ne 1
=CraphuaLa!M14
1ota| 1en-ear State Cost: 5832 M||||on
47.3
42.9
S3.S
79.3
72.2
kev|sed 1en-ear State Cost |f n|gher IMA |s Den|ed: 586S M||||on
kev|sed 1ota|s |f n|gher IMA |s Den|ed
54.4
52.6
5S.3
54.S
52.S
53.0
53.S
54.0
54.S
5S.0
5S.S
56.0
2
0
1
1
-
1
2
2
0
1
2
-
1
3
2
0
1
3
-
1
4
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
8
|
|
|
|
o
n
s
State I|sca| ear
Ma|neCare 1ota| Cost Iorecast
"#$%&' ?A) 26.#51.'/ I+6. +7 29:136#+3 +P'& ;16'4#3' (
1he expanslon scenarlo
assumes Lhe lederal
governmenL wlll conLlnue
Lo provlde 90 fundlng
afLer 2020, buL Lhls
assumpLlon ls noL assured
conslderlng Lhe flscal
slLuaLlon of Lhe federal
governmenL.
age: 61
Clven Lhese same assumpLlons, I|gure 41 shows Lhe expanslon forecasL of Lhe AC llnanclal Model
when compared Lo Lhe 8asellne 2 scenarlo. SLaLe cosLs wlll be $13.3 mllllon ln Sl? 201413, or $23.2
mllllon lf Lhe hlgher lMA ls denled for Lhe chlldless adulL walver populaLlon. 1hese sLaLe cosLs are
pro[ecLed Lo grow Lo $92.3 mllllon ln Sl? 202324, for a Len-year LoLal of $347 mllllon, or $380
mllllon lf Lhe hlgher lMA ls denled.
13.3
10.0
22.4
42.6
S0.7
6S.8
79.1
83.3
87.8
92.S
5-
5S0
5100
51S0
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
M
|
|
|
|
o
n
s
State I|sca| ear
1ota| 1en-ear State Cost: 5S47 M||||on
2S.2
19.S
28.9
S1.9
46.3
kev|sed 1en-ear State Cost |f n|gher IMA |s Den|ed: 5S80 M||||on
kev|sed 1ota|s |f n|gher IMA |s Den|ed
"#$%&' ?() 26.#51.'/ I+6. +7 29:136#+3 +P'& ;16'4#3' 8
age: 62
I|gure 42 provldes a more deLalled summary of Lhe scenarlo resulLs of Lhe AC llnanclal Model, whlch lncludes Lhe basellne forecasL, Lhe
slmple expanslon proposal forecasL, and Lhe lmpacL of Lhe forecasL. lL glves Lhe pro[ecLed populaLlons, LoLal cosLs, federal cosLs, and sLaLe
cosLs.

SI: 2012-13
Actua|
2013-14
Lst|mate
2014-1S
Iorecast
201S-16
Iorecast
2016-17
Iorecast
2017-18
Iorecast
2018-19
Iorecast
2019-20
Iorecast
2020-21
Iorecast
2021-22
Iorecast
2022-23
Iorecast
2023-24
Iorecast
1en ear
1ota|
Lnro||ees 306,732 281,147 276,231 284,068 292,118 300,410 308,949 317,743 326,800 336,128 343,734 333,628
1ota| Cost 2,639 $ 2,633 $ 2,699 $ 2,843 $ 3,001 $ 3,167 $ 3,343 $ 3,329 $ 3,726 $ 3,934 $ 4,133 $ 4,388 $ 34,783 $
Ied Cost 1,612 $ 1,382 $ 1,607 $ 1,709 $ 1,809 $ 1,910 $ 2,018 $ 2,132 $ 2,232 $ 2,379 $ 2,314 $ 2,637 $ 20,987 $
State Cost 1,047 $ 1,031 $ 1,092 $ 1,134 $ 1,192 $ 1,237 $ 1,323 $ 1,398 $ 1,474 $ 1,333 $ 1,641 $ 1,731 $ 13,798 $
Lnro||ees 306,732 281,147 292,936 301,167 309,641 318,367 327,331 336,602 346,127 333,934 366,032 376,429
1ota| Cost 2,639 $ 2,633 $ 2,737 $ 2,904 $ 3,063 $ 3,234 $ 3,414 $ 3,604 $ 3,803 $ 4,018 $ 4,243 $ 4,481 $ 33,324 $
Ied Cost 1,612 $ 1,382 $ 1,643 $ 1,746 $ 1,848 $ 1,932 $ 2,062 $ 2,178 $ 2,301 $ 2,431 $ 2,368 $ 2,714 $ 21,442 $
State Cost 1,047 $ 1,031 $ 1,114 $ 1,138 $ 1,216 $ 1,282 $ 1,332 $ 1,426 $ 1,303 $ 1,387 $ 1,673 $ 1,767 $ 14,082 $
Lnro||ees 376,870 387,223 397,873 408,830 420,102 431,699 443,629 433,903 468,330 481,320
1ota| Cost 3,279 $ 3,433 $ 3,643 $ 3,847 $ 4,060 $ 4,283 $ 4,323 $ 4,774 $ 3,041 $ 3,322 $ 42,229 $
Ied Cost 2,132 $ 2,287 $ 2,406 $ 2,321 $ 2,636 $ 2,793 $ 2,939 $ 3,104 $ 3,278 $ 3,463 $ 27,600 $
State Cost 1,127 $ 1,168 $ 1,239 $ 1,323 $ 1,403 $ 1,492 $ 1,384 $ 1,670 $ 1,762 $ 1,839 $ 14,629 $
Lnro||ees 100,620 103,133 103,733 108,421 111,134 113,936 116,829 119,773 122,793 123,892
1ota| Cost 380 $ 611 $ 643 $ 680 $ 717 $ 736 $ 797 $ 840 $ 886 $ 934 $ 7,444 $
Ied Cost 344 $ 378 $ 398 $ 611 $ 639 $ 661 $ 687 $ 723 $ 764 $ 806 $ 6,613 $
State Cost 33 $ 33 $ 47 $ 69 $ 78 $ 93 $ 110 $ 113 $ 122 $ 128 $ 832 $
Lnro||ees 83,933 86,036 88,232 90,463 92,731 93,097 97,302 99,969 102,498 103,091
1ota| Cost 322 $ 331 $ 381 $ 612 $ 643 $ 681 $ 718 $ 737 $ 798 $ 841 $ 6,703 $
Ied Cost 309 $ 341 $ 338 $ 370 $ 393 $ 613 $ 638 $ 673 $ 710 $ 749 $ 6,138 $
State Cost 13 $ 10 $ 22 $ 43 $ 31 $ 66 $ 79 $ 83 $ 88 $ 92 $ 347 $
8
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1he A|exander Group I|nanc|a| Mode| kesu|ts for Med|ca|d Lxpan|on |n Ma|ne: Do||ars |n M||||ons
"#$%&' ?8) @S' U4'913/'& >&+%: "#313-#14 0+/'4 C'6%4.6
1he Alexander Croup age: 63
l|sca| lmoact
Malne already has a relaLlvely hlgh percenLage of lLs overall sLaLe populaLlon enrolled ln MalneCare,
whlch was 22.6 ln Sl? 2012-13. (See I|gure 43.) 8ased on Lhe acLuarlal assumpLlons used ln Lhls
flnanclal model, 23.4 of Lhe overall sLaLe populaLlon wlll be enrolled ln Medlcald by Sl? 2023-24
under Lhe 8asellne 1 scenarlo, or one ln every four persons. lor Lhe
8asellne 2 scenarlo, 26.9 of Lhe overall wlll be enrolled ln
MalneCare. WlLh expanslon, however, 34.4 of Lhe overall sLaLe
populaLlon wlll be enrolled ln Medlcald, or one ln every Lhree
persons. 1hese percenLages do noL lnclude Lhe approxlmaLely
43,000 lndlvlduals who recelve parLlal beneflLs from MalneCare.
(See Append|x 8 for more deLalls on assumpLlons).
Carrylng Lhe healLh-care needs of one Lhlrd of Lhe populaLlon wlll be challenglng under any
clrcumsLance. Average cosLs Lo fund healLhcare for members enrolled ln MalneCare vary greaLly
among populaLlon groups, from as llLLle as $3,848 annually ln Sl? 201213 for chlldren under 100
of lL Lo $18,641 for lndlvlduals wlLh dlsablllLles.
"#$%&' ?=) 01#3'I1&' 16 *'&-'3. +7 K.1.' *+:%41.#+3
22.6
20.7
2S.4
1.2
1.S
6.3
7.S
0.0
S.0
10.0
1S.0
20.0
2S.0
30.0
3S.0
2012-13
Actua|
201S-16
Iorecast
2023-24
Iorecast
Ma|neCare
1
As ercent of State opu|at|on
Lxpans|on
arents 101 - 138 IL
8ase||ne 1
noLe:
1
lncludes only
28.2
34.4
WlLh Medlcald expanslon,
34.4 of Maines
populaLlon wlll be enrolled
ln Medlcald by Sl? 2023-
24.
ln Lerms of sLaLe funds, Lhe budgeL for MalneCare
servlces has been growlng fasLer Lhan Lhe resL of Lhe
sLaLe budgeL, almosL Lhree Llmes as fasL over Lhe pasL
Len years (6.0 average annual growLh versus 2.2).
1he AC llnanclal Model forecasLs LhaL Lhe basellne
average annual growLh raLe wlll be sllghLly more aL
3.1 for Lhe 8asellne 1 scenarlo or 3.3 for Lhe
8asellne 2 scenarlo. Powever, lf Malne elecLs Lo
expand Lhe MalneCare ellglblllLy, Lhe forecasLed growLh raLe becomes 3.9. I|gure 44 lllusLraLes Lhe
dlfferences ln Lhe growLh raLes, whlch are Lhe flnanclal obllgaLlons LhaL musL be pald for uslng sLaLe
funds. 1he large dlp ln Lhe sLaLe obllgaLlon for MalneCare servlces seen on Lhe charL occurred
because Lhe federal governmenL, Lhrough Lhe Amerlcan 8ecovery and 8elnvesLmenL AcL of 2009,
provlded sLaLes wlLh one-Llme granLs Lo help pay for Medlcald and balance Lhelr budgeLs durlng Lhe
lasL recesslon. lmporLanLly, Lhese dlfferences ln Lhe growLh raLes ralse an obvlous flscal concern: Lhe
sLaLe wlll conLlnually have Lo generaLe addlLlonal revenue Lo supporL Lhe program, even wlLhouL Lhe
expanslon

1he varylng growLh raLes wlll cause MalneCare servlces Lo conLlnually encompass a larger share of
Lhe sLaLe budgeL ln regards Lo boLh sLaLe funds and federal funds. I|gure 4S shows Lhe resulLs of
1.0
1.S
2.0
2.S
3.0
3.S
2
0
0
2
-
0
3
2
0
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-
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State I|sca| ear
Ma|neCare Serv|ces and kest of 8udget Growth Compar|son
State Iunds Cn|y
Ma|neCare Serv|ces
8ase||ne 1 Iorecast
8ase||ne 2 Iorecast
Lxpans|on Iorecast
kest of 8udget (kC8)
kC8 1rend||ne
"#$%&' ??) 01#3'I1&' K'&P#-'6 13/ ;%/$'. >&+E.S I+5:1&#6+3
ln Lerms of sLaLe funds, Lhe budgeL for
MalneCare servlces has been growlng
fasLer Lhan Lhe resL of Lhe sLaLe budgeL,
almosL Lhree Llmes as fasL over Lhe pasL
Len years (6.0 average annual growLh
versus 2.2.)
esLlmaLlng Lhe budgeL lmpacL. PlsLorlc growLh raLes were used Lo esLlmaLe Lhe slze of Lhe resL of Lhe
budgeL along wlLh Lhe resulLs of Lhe AC llnanclal Model for esLlmaLlng Lhe cosLs of MalneCare
servlces. Lxamlnlng [usL Lhe Ceneral lund, Lhe percenLage of Lhe Ceneral lund budgeL dedlcaLed Lo
MalneCare servlces was 20.3 ln Sl? 200203. 1hls percenLage grew Lo 24.2 ln Sl? 201213, and
Lhe AC llnanclal Model forecasLs LhaL lL wlll become 33.9 ln Sl? 202324 under Lhe 8asellne 1
scenarlo. 1he percenLage for Sl? 2012-13 would be even hlgher lf MalneCare were noL
supplemenLed wlLh $233 mllllon from oLher speclal revenue accounLs. lor Lhe 8asellne 2 scenarlo,
anoLher full percenLage polnL would be needed Lo fund MalneCare ln Sl? 2023-24, brlnglng Lhe LoLal
Lo 34.9. under Lhe expanslon scenarlo, however, MalneCare wlll requlre 36.4 of Lhe Ceneral
lund budgeL. lor Lhe overall budgeL, lncludlng federal funds, MalneCare wlll requlre 43.9 of Lhe
LoLal budgeL under expanslon ln Sl? 2023-24 as opposed Lo 38.6 under Lhe 8asellne 1 scenarlo.
AlLhough an economlc lmpacL sLaLemenL ls beyond Lhe scope of Lhls sLudy, some observaLlons are
offered. llrsL, however, a word needs Lo be sald abouL a number of recenL economlc sLudles LhaL
have been produced predlcLlng economlc beneflLs for sLaLes LhaL expand. 1hese sLudles appear Lo
use LheoreLlcal assumpLlons from Lhe neo-keyneslan school of economlc LhoughL. 1hey generally
use models LhaL apply a mulLlpller Lo new spendlng Lo demonsLraLe lncreased economlc acLlvlLy.
1hese models are serlously deflclenL, however, because Lhey do noL adequaLely accounL for all
economlc losses from Lhe revenue slde of Lhe equaLlon. A more vlable model would also esLlmaLe
Lhe opporLunlLy cosLs due Lo Lhe lncreased LaxaLlon, governmenL borrowlng, and oLher lmpacLs. lL
ls Lhe neL of Lhe beneflLs and losses LhaL deflnes Lhe economlc lmpacL.
"#$%&' ?H) 01#3'I1&' K'&P#-'6 16 *'&-'3. +7 01#3' K.1.' ;%/$'. LG "%3/
8ase||ne 2
Ceneral
lund
All SLaLe
lunds
lederal 1oLal
Ceneral
lund
Ceneral
lund
All SLaLe
lunds
lederal 1oLal
2002-03 (AcLual) 20.3 13.9 39.0 29.0 20.3 n/A n/A n/A n/A
2012-13 (AcLual) 24.2 19.0 39.2 32.2 24.2 n/A n/A n/A n/A
2023-24 (lorecasL) 33.9 24.1 64.9 38.6 34.9 36.4 23.9 70.8 43.9
ercent Med|ca| Serv|ces to 1ota| Ma|ne State 8udget by Iunds
8ase||ne 1 Lxpans|on
Sl?
Cne qulck way Lo evaluaLe Lhe economlc lmpacL ls Lo compare MalneCare enrollmenL Lo
employmenL. 1hls glves an lndlcaLlon of Lhe burden placed on Lhe employed who supporL Lhe
sysLem. 1hls ls noL an exacL lndlcaLor by any means, buL lL neverLheless provldes a rough lndlcaLlon.
lL ls, afLer all, Lhose who are employed who pay Lhe bulk of Laxes Lo supporL noL only sLaLe
governmenL buL Lhe federal governmenL as well. uslng daLa from Lhese sourcesLhe u.S. 8ureau of
Labor SLaLlsLlcs, Lhe CenLer for Workforce 8esearch and lnformaLlon of Lhe Malne ueparLmenL of
Labor, and Lhe Malne ueparLmenL of PealLh and Puman Servlcesand forecasLs from Lhe AC
llnanclal Model, Lhe enrollmenL Lo employmenL raLlo changes under expanslon. ln Sl? 201213, Lhe
raLlo was 1 Lo 1.9, meanlng LhaL each person on MalneCare was supporLed by 1.9 employed persons.
1he forecasLs show LhaL LhaL raLlo wlll drop Lo 1 Lo 1.4 ln 2020 under Lhe expanslon scenarlo. (See
I|gures 46 and 47.)
Ma|neCare
Lnro||ee
Lmp|oyed
Ma|ners
Lach Ma|neCare enro||ee was
supported by 1.9 emp|oyed
Ma|ners |n SI 2012-13.
Lach Ma|neCare enro||ee w|||
||ke|y be supported by on|y
1.4 emp|oyed Ma|ners |n
2020.
Under Ma|neCare Lxpans|on:
"#$%&' ?N) 01#3'I1&' 23&+44''6 .+ 25:4+G'/ 01#3'&6 C1.#+
1he enrollmenL Lo employmenL raLlo changes under expanslon. ln Sl? 201213, Lhe raLlo was 1 Lo
1.9, meanlng LhaL each person on MalneCare was supporLed by 1.9 employed persons. 1he forecasLs
show LhaL LhaL raLlo wlll drop Lo 1 Lo 1.4 ln 2020 under Lhe expanslon scenarlo.

Conc|us|on on 8esu|ts o l|nanc|a| Mooe|
lrom a flnanclal sLandpolnL, Lhe resulLs from Lhe basellne and
expanslon scenarlos are Lroublesome. CrlLlcal facLors, such as
poverLy growLh, are causlng MalneCare Lo conLlnue Lo have
hlgh-cosL growLh far ln excess of oLher budgeLary growLh. ln
oLher words, Lhe SLaLe of Malne wlll be challenged Lo
generaLe addlLlonal revenue ln sLaLe funds Lo keep up wlLh
Lhe growlng demand for MalneCare under Lhe 8asellne 1
forecasL, whlch ls pro[ecLed Lo requlre 33.9 of Lhe Ceneral lund budgeL ln Sl? 2023-24 when lL
now requlres 24.2 of Lhe Ceneral lund budgeL. An addlLlonal $284 mllllon over Len years would
be requlred Lo supporL Lhe MalneCare under Lhe 8asellne 2 scenarlo. lor Lhe expanslon scenarlo,
Lhe sLaLe of Malne would be requlred Lo generaLe an addlLlonal $832 mllllon Lo $863 mllllon ln sLaLe
funds over Lhe nexL Len years ln addlLlon Lo whaL ls requlred Lo supporL MalneCare under Lhe
8asellne 1 scenarlo. 1he nexL secLlon examlnes rlsks Lo Lhese forecasLs.

S1S,82S
322,272
496,967
306,7S2
99,9S0
11S,392
100,767
0 100,000 200,000 300,000 400,000 S00,000 600,000 700,000
Compar|ng Ma|neCare Lnro||ment
1
to Lmp|oyment
Lnro||ment to
Lmp|oyment kat|o:
Lnro||ment to
Lmp|oyment kat|o:
Ma|neCare
Lnro||ment
|n 2012-13
Ma|neCare
Lnro||ment
|n 2020
Lmp|oyment
|n 2012-13
Lmp|oyment
|n 2020
S97,733
437,664
61S,77S
r|vate
r|vate
Government-->
Government-->
Lxpans|on opu|at|on
1 to 1.4
1 to 1.9
Date Sources: Lstab||shment data of the U.S. 8ureau of Labor Stat|st|cs, 2020 ro[ect|ons from the Ma|ne Department of Labor,
Center for Workforce kesearch and Informat|on, Ma|ne Department of nea|th & numan Serv|ces, and A|exander Group Iorecasts.
Note:
1
Inc|udes on|y enro||ees w|th fu|| benef|ts.
"#$%&' ?R) 01#3'I1&' 23&+445'3. .+ 25:4+G5'3. I+5:1&#6+3
1he resulLs of Lhe basellne and
expanslon scenarlos wlll
challenge Malne Lo generaLe
addlLlonal revenue ln sLaLe funds
Lo keep up wlLh Lhe growlng
demand for MalneCare.


Sect|on VI: k|sk Ana|ys|s

Sect|on vl: 8|s| Ana|ys|s
Cvev|ew
1he scenarlos generaLed by Lhe flnanclal model Lo forecasL Lhe basellne and expanslon enrollmenL
and cosLs are based on a number of key assumpLlons on values of facLors LhaL wlll deLermlne whaL
Lrends wlll prevall ln Lhe fuLure. Lach value chosen was ln Lhe mlddle of an expecLed range of
posslblllLles. lor example, Lhe MM growLh facLor has an expecLed value range of 1.9 Lo 3.9,
and 2.9 was Lhe chosen value for Lhe forecasL. 1here ls rlsk, however, LhaL Lhe acLual value LhaL
wlll be reallzed ln Lhe fuLure wlll fall Loward elLher end of Lhe range as opposed Lo ln Lhe mlddle.
Low-end values are deflned as Lhose values LhaL would cause enrollmenL and cosLs Lo be lower Lhan
forecasLed. Plgh-end values are Lhose values LhaL would cause enrollmenL and cosL Lo be more Lhan
forecasLed. 1hls secLlon of Lhe reporL provldes analysls on Lhe four mosL llkely rlsk facLors.
1|e 8|s| lactos Cons|oeeo
1he four rlsk facLors chosen Lo be analyzed are Lhe poverLy growLh raLes, MM growLh raLes,
lndlvlduals wlLh prlvaLe lnsurance loslng coverage (prlvaLe drop), and lMA raLe changes. (See
I|gure 48.)
Lach of Lhe succeedlng pages presenLs Lhree posslblllLles for each rlsk facLor:
Low end values are those values that result in the overall decrease in costs, which may
lnclude reducLlons ln enrollmenL, relaLlve Lo whaL ls expecLed.
High-end values are those values LhaL resulL ln Lhe overall lncrease ln cosLs, whlch may
lnclude lncreases ln enrollmenL, relaLlve Lo whaL ls expecLed.
k|sk Iactor Lxp|anat|on Impact
overLy CrowLh Small changes ln poverLy growLh lnfluences welfare rolls. lmpacLs slze of populaLlon ellglble for
MalneCare and overall sLaLe budgeL.
MM PealLh care cosLs have been lncreaslng, and Malne's fee
relmbursemenL raLe relaLlve Lo prlvaLe lnsurers ls one of
Lhe lowesL ln Lhe counLry.
8lslng cosLs lmpacL LoLal program cosLs
and Lhe sLaLe budgeL.
rlvaLe urop ersons loslng coverage wlLhln deflned lncome ranges
can become ellglble for MalneCare.
lmpacLs slze of populaLlon ellglble for
MalneCare and overall sLaLe budgeL.
lMA lMA raLes deLermlne cosL sharlng beLween Lhe federal
governmenL and sLaLe governmenLs.
Changes ln lMA raLes have slgnlflcanL
lmpacL on sLaLe budgeLs.
k|sk Iactors Lxam|ned
"#$%&' ?V) C#6D "1-.+&6 2915#3'/

Middle values are values between the low-end and hlgh-end and are subsequenLly
considered to be more likely or what is expected. These middle values are also the
assumpLlons LhaL were chosen ln Lhe scenarlos presenLed ln Sect|on V.
1he above values lmpacL boLh Lhe basellne and expanslon scenarlos.
1he nexL four subsecLlons provlde analysls on Lhe poLenLlal low-end and hlgh-end values for Lhe four
rlsk facLors llsLed above. 1he flfLh subsecLlon below provldes an analysls on whaL mlghL be a besL
case scenarlo and a worsL case scenarlo, assumlng LhaL Lhe Lhree of Lhose four rlsk facLors wlll have
values LhaL fall on elLher Lhe low-end or hlgh-end of Lhelr respecLlve ranges. 1he Lhree facLors chosen
are Lhose facLors mosL llkely Lo vary from Lhe mlddle.
AL Lhe Lop of each subsecLlon below are Lhree summary boxes as follows:
Summary 8ox 1 provldes Lhe low-end, mlddle, and hlgh-end values for Lhe rlsk facLor belng
consldered.
Summary 8ox 2 provldes a summary of Lhe lmpacL assumlng Lhe low-end and hlgh end
values on four program meLrlcs as Lhey relaLe Lo Lhe 8asellne 1, 8asellne 2, and expanslon
scenarlos. 1he four program meLrlcs are enrollmenL ln Sl? 2023-24, percenL of Lhe
populaLlon on MalneCare ln Sl 2023-24, Lhe Len-year LoLal cosL ln mllllons of dollars, and Lhe
Len-year sLaLe cosL ln mllllons of dollars. 1hls box shows Lhe lmpacL of Lhose values on Lhose
meLrlcs by showlng how resulLs vary assumlng Lhe mlddle value, Lhe low-end value, and Lhe
hlgh-end value. 1he box furLher shows Lhe dlfferences and percenL changes from Lhe mlddle
value Lo boLh Lhe low-end and hlgh-end resulLs.
Summary 8ox 3 shows how Lhe resulLs change by assumlng Lhe low-end and hlgh-end values
and Lhelr lmpacL on Lhe expanslon scenarlo relaLlve Lo Lhelr respecLlve 8asellne 1 and
8asellne 2 scenarlos. lor example, Lhe resulL of a low-end value assumpLlon for expanslon
would be compared Lo a basellne assumlng Lhe same low-end value. 1he four meLrlcs
consldered are Lhe addlLlonal enrollmenL for Sl? 2023-24, Lhe addlLlonal percenLage of Lhe
populaLlon on MalneCare ln Sl? 2023-24, Lhe addlLlonal Len-year LoLal cosL ln mllllons of
dollars, and Lhe addlLlonal Len-year sLaLe cosL ln mllllons of dollars.


lovety Cowt| 8|s| lacto
AcLuarlal analysls was used Lo evaluaLe Lhe poverLy growLh facLor ln Malne, whlch has been very
hlgh as explalned earller ln Lhe reporL. lf Lhe poverLy raLe lncreases more Lhan expecLed, lL wlll lead
Lo more persons quallfylng for MalneCare. Llkewlse, lf lL grows less Lhan expecLed, lL can reduce Lhe
number. I|gures 49, S0, and S1 summarlze poLenLlal facLors and resulLs.

"#$%&' ?W) *+P'&.G >&+E.S C#6D "1-.+&6
Age Category Low Lnd M|dd|e n|gh Lnd
under 18 2.31 3.08 3.83
18 Lo 64 1.86 2.48 3.10
63 and over 2.71 3.61 4.31
1oLal 2.09 2.78 3.48
opu|at|on Growth Iactors
Summary 8ox 1
M|dd|e
kesu|t kesu|t D|fference kesu|t D|fference
LnrollmenL ln Sl? 2023-24 333,628 331,372 -24,236 -6.8 381,318 23,890 7.3
ercenL of opulaLlon on
MalneCare ln Sl? 2023-24
23.4 23.7 -1.7 27.3 1.9
10 ?ear 1oLal CosL (Mllllons $) 34,784.9 33,493.3 (1,291.4) -3.7 36,137.7 1,332.8 3.9
10 ?ear SLaLe CosL (Mllllons $) 13,797.7 13,312.1 (483.6) -3.3 14,306.3 308.6 3.7
LnrollmenL ln Sl? 2023-24 376,429 330,829 -23,399 -6.8 403,746 27,317 7.3
26.9 23.1 -1.8 28.9 2.0
LnrollmenL ln Sl? 2023-24 481,320 430,228 -31,292 -6.3 314,819 33,299 6.9
34.4 32.2 -2.2 36.8 2.4
Summary 8ox 2
Low Lnd n|gh Lnd
Scenar|o and rogram Metr|c
8
a
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e
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e

1
8
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2
L
x
p
a
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s
|
o
n
overty Growth k|sk Iactor Changes to Assumed M|dd|e Va|ues
"#$%&' HA) *+P'&.G >&+E.S C#6D "1-.+& IS13$'6 .+ U66%5'/ 0#//4' \14%'6

"#$%&' H() 29:136#+3 X5:1-. +7 *+P'&.G >&+E.S C#6D "1-.+&6
Increase Increase Increase
AddlLlonal LnrollmenL ln Sl? 2023-24 118,836 33.9 123,892 33.4 133,301 34.9
AddlLlonal of opulaLlon on MalneCare ln Sl? 2023-24 8.3 9.0 9.3
AddlLlonal 10 ?ear 1oLal CosL (Mllllons $) 7,217.3 21.3 7,444.3 21.4 7,679.3 21.3
AddlLlonal 10 ?ear SLaLe CosL (Mllllons $) 801.1 6.0 831.7 6.0 863 6.0
AddlLlonal 10 ?ear SLaLe CosL (Mllllons $) 328.6 3.9 347.4 3.9 367.0 3.9
Summary 8ox 3
I
m
p
a
c
t

t
o
8
a
s
e
|
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n
e

1
I
m
p
a
c
t

t
o
8
a
s
e
|
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n
e

2
Lxpans|on Impact of overty Growth k|sk Iactors
Low Lnd M|dd|e n|gh Lnd

overty Growth k|sk Iactor Impact on 1ota| overty Chart: A change ln Lhe growLh facLor wlll
lmpacL Lhe number of persons ln poverLy. I|gure S2 summarlzes Lhe lmpacL of Lhe varlous growLh
facLors. 1he solld llne lndlcaLes Census 8ureau esLlmaLes on Lhe number of persons ln poverLy. 1he
doLLed llnes are forecasLs uslng acLuarlal assumpLlons.

"#$%&' H8) C13$' +7 U-.%1&#14 "+&'-16. +7 *'&6+36 #3 *+P'&.G
124,727
169,076
24S,317
229,224
186,484
262,419
100,000
120,000
140,000
160,000
180,000
200,000
220,000
240,000
260,000
280,000
2000 200S 2010 201S 2020
Actuar|a| Iorecast of ersons |n overty
Lst|mate for 2012
kange of Actuar|a| Iorecast

overty Growth k|sk Iactor Impact on Ch||dren Chart: I|gure S3 shows how Lhe dlfferenL growLh
facLors would lmpacL Lhe forecasL for chlldren llvlng ln poverLy. 1he solld llne lndlcaLes Census
8ureau esLlmaLes on Lhe number of chlldren ln poverLy. 1he doLLed llnes are forecasLs uslng acLuarlal
assumpLlons.

36,S40
48,734
69,S97
64,S69
S1,386
74,974
30,000
3S,000
40,000
4S,000
S0,000
SS,000
60,000
6S,000
70,000
7S,000
80,000
2000 200S 2010 201S 2020
Actuar|a| Iorecast of Ch||dren |n overty
Lst|mate for 2012
kange of Actuar|a| Iorecast
"#$%&' H=) C13$' +7 U-.%1&#14 "+&'-16. +7 IS#4/&'3 #3 *+P'&.G

overty Growth k|sk Iactor Impact on Lnro||ment Chart re|at|ve to 8ase||ne 1: I|gure S4 dlsplays
how dlfferenL poverLy growLh facLors would lmpacL MalneCare enrollmenL.

3SS,628
281,147
481,S20
32S,384
381,S18
444,739
S33,984
2S0,000
300,000
3S0,000
400,000
4S0,000
S00,000
SS0,000
2
0
1
1
-
1
2
2
0
1
2
-
1
3
2
0
1
3
-
1
4
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
M
a
|
n
e
C
a
r
e

L
n
r
o
|
|
m
e
n
t
State I|sca| ear
1
Iorecast
noLe:
1
lncludes only
"#$%&' H?) *+P'&.G C#6D "1-.+& X5:1-. +3 01#3'I1&' 23&+445'3. "+&'-16. ;16'4#3' (

overty Growth k|sk Iactor Impact on Lnro||ment Chart re|at|ve to 8ase||ne 2: I|gure SS dlsplays
how dlfferenL poverLy growLh facLors would lmpacL MalneCare enrollmenL.

376,429
281,147
481,S20
32S,384
403,746
444,739
S33,984
2S0,000
300,000
3S0,000
400,000
4S0,000
S00,000
SS0,000
2
0
1
1
-
1
2
2
0
1
2
-
1
3
2
0
1
3
-
1
4
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
M
a
|
n
e
C
a
r
e

L
n
r
o
|
|
m
e
n
t
State I|sca| ear
1
Iorecast
noLe:
1
lncludes only
"#$%&' HH) *+P'&.G C#6D "1-.+& X5:1-. +3 01#3'I1&' 23&+445'3. "+&'-16. ;16'4#3' 8

overty Growth k|sk Iactor Impact on Ma|neCare as a ercent of State opu|at|on: Assumlng Lhe
low-end facLors for poverLy growLh, lL ls anLlclpaLed LhaL wlLh expanslon 32.2 of Lhe Malne
populaLlon would be servlced by MalneCare by Sl? 2022-23. lf Lhe poverLy raLe grows more qulckly
Lhan anLlclpaLed, 36.8 of Lhe populaLlon would be servlced by MalneCare. (See I|gure S6.)

27.9
32.2
22.6
28.2
34.4
28.6
36.8
0.0
S.0
10.0
1S.0
20.0
2S.0
30.0
3S.0
40.0
2012-13 Actua| 201S-16 Iorecast 2023-24 Iorecast
Ma|neCare
1
Low Lnd Mlddle Plgh Lnd
noLe:
1
lncludes only
"#$%&' HN) *+P'&.G C#6D "1-.+& X5:1-. +3 01#3'I1&' 16 *'&-'3. +7 K.1.' *+:%41.#+3

overty Growth k|sk Iactor Impact on 1ota| Cost of Ma|neCare re|at|ve to 8ase||ne 1: 1hls charL
provldes a graphlc presenLaLlon on how Lhe LoLal cosLs can vary based on Lhe poLenLlal varlablllLy ln
poverLy growLh raLes. (See I|gure S7.)

54.1
52.6
54.4
54.7
5S.0
5S.3
5S.7
52.S
53.0
53.S
54.0
54.S
5S.0
5S.S
56.0
2
0
1
1
-
1
2
2
0
1
2
-
1
3
2
0
1
3
-
1
4
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
8
|
|
|
|
o
n
s
State I|sca| ear
"#$%&' HR) *+P'&.G C#6D "1-.+& X5:1-. +3 01#3'I1&' @+.14 I+6. "+&'-16. ;16'4#3' (

overty Growth k|sk Iactor Impact on 1ota| Cost of Ma|neCare re|at|ve to 8ase||ne 2: 1hls charL
poverLy growLh raLes. (See I|gure S8.)

54.2
52.6
54.S
54.8
5S.0
5S.3
5S.7
52.S
53.0
53.S
54.0
54.S
5S.0
5S.S
56.0
2
0
1
1
-
1
2
2
0
1
2
-
1
3
2
0
1
3
-
1
4
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
8
|
|
|
|
o
n
s
State I|sca| ear
"#$%&' HV) *+P'&.G C#6D "1-.+& X5:1-. +3 01#3'I1&' @+.14 I+6. "+&'-16. ;16'4#3' 8

overty Growth k|sk Iactor Impact on 1ota| Cost of Lxpans|on ke|at|ve to 8ase||ne 1: 1hls charL
provldes a graphlc presenLaLlon on how Lhe LoLal cosLs of Lhe expanslon scenarlo can vary based on
Lhe poLenLlal varlablllLy ln poverLy growLh raLes. (See I|gure S9.)

S
7
9
.
1
6
0
6
.
9
6
3
6
.
1
6
6
6
.
6
6
9
8
.
6
7
3
2
.
2
7
6
7
.
4
8
0
4
.
3
8
4
2
.
9
8
8
3
.
4
S
7
9
.
8
6
1
1
.
3
6
4
4
.
6
6
7
9
.
6
7
1
6
.
6
7
S
S
.
6
7
9
6
.
7
8
4
0
.
1
8
8
S
.
8
9
3
4
.
1
S
8
0
.
S
6
1
S
.
8
6
S
3
.
2
6
9
2
.
8
7
3
S
.
0
7
7
9
.
6
8
2
7
.
0
8
7
7
.
4
9
3
0
.
7
9
8
7
.
4
50
5100
5200
5300
5400
5S00
5600
5700
5800
5900
51,000
51,100
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
M
|
|
|
|
o
n
s
State I|sca| ear
Lst|mated 1ota| Cost of Lxpans|on over 8ase||ne 1
Low Lnd 10-ear Cost: 57.2 8||||on
M|dd|e Case 10-ear Cost: 57.4 8||||on
n|gh Lnd 10-ear Cost: 57.7 8||||on
"#$%&' HW) *+P'&.G C#6D "1-.+& X5:1-. +3 @+.14 I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' (

overty Growth k|sk Iactor Impact on 1ota| Cost of Lxpans|on ke|at|ve to 8ase||ne 2: 1hls charL
provldes a graphlc presenLaLlon on how Lhe LoLal cosLs of Lhe expanslon scenarlo can vary based on
Lhe poLenLlal varlablllLy ln poverLy growLh raLes. (See I|gure 60.)

"#$%&' NA) *+P'&.G C#6D "1-.+& X5:1-. +3 @+.14 I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' 8
S
2
2
.
3
S
4
7
.
3
S
7
3
.
6
6
0
1
.
1
6
3
0
.
0
6
6
0
.
3
6
9
2
.
0
7
2
S
.
2
7
6
0
.
1
7
9
6
.
6
S
2
2
.
3
S
S
0
.
6
S
8
0
.
6
6
1
2
.
1
6
4
S
.
4
6
8
0
.
6
7
1
7
.
6
7
S
6
.
7
7
9
7
.
8
8
4
1
.
3
S
2
2
.
3
S
S
4
.
0
S
8
7
.
6
6
2
3
.
3
6
6
1
.
2
7
0
1
.
4
7
4
4
.
0
7
8
9
.
2
8
3
7
.
3
8
8
8
.
2
50
5100
5200
5300
5400
5S00
5600
5700
5800
5900
51,000
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
M
|
|
|
|
o
n
s
State I|sca| ear
Low Lnd 10-ear Cost: 56.S 8||||on

overty Growth k|sk Iactor Impact on State Cost of Lxpans|on re|at|ve to 8ase||ne 1: 1hls charL
provldes a graphlc presenLaLlon on how Lhe sLaLe cosLs of Lhe expanslon scenarlo can vary based on

"#$%&' N() *+P'&.G C#6D "1-.+& X5:1-. +3 K.1.' I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' (

3
S
.
2
3
2
.
9
4
6
.
1
6
7
.
07
S
.
9
9
1
.
61
0
S
.
4
1
1
0
.
4
1
1
S
.
6
1
2
1
.
1
3
S
.
4
3
3
.
4
4
7
.
0
6
8
.
S7
8
.
1
9
4
.
6
1
0
9
.
S
1
1
S
.
4
1
2
1
.
6
1
2
8
.
1
3
S
.
7
3
3
.
9
4
7
.
9
7
0
.
1
8
0
.
2
9
7
.
8
1
1
3
.
8
1
2
0
.
7
1
2
7
.
9
1
3
S
.
6
5-
5S0
5100
51S0
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
M
|
|
|
|
o
n
s
State I|sca| ear
Low Lnd 10-ear Cost: 5801 M||||on
M|dd|e Case 10-ear Cost: 5832 M||||on
n|gh Lnd 10-ear Cost: 5863 M||||on
Assumes n|gher IMA for Ch||d|ess Adu|ts under Wa|ver

overty Growth k|sk Iactor Impact on State Cost of Lxpans|on re|at|ve to 8ase||ne 2: 1hls charL
provldes a graphlc presenLaLlon on how Lhe sLaLe cosLs of Lhe expanslon scenarlo can vary based on

"#$%&' N8) *+P'&.G C#6D "1-.+& X5:1-. +3 K.1.' I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' 8



lMlM 8|s| lacto
1he second rlsk facLor belng consldered ls Lhe MM growLh facLor. 1he mlddle value was based on
compuLaLlons by Lhe uSuPPS Cfflce of Lhe AcLuary. 1he low-end value assumes LhaL cosLs would
grow by a full percentage point below that calculation. However, Maines fee reimbursement is one
of Lhe lowesL ln Lhe naLlon compared Lo prlvaLe relmbursemenL raLes, whlch lndlcaLes Lhere may be
upward pressure Lo lncrease Lhe raLes. 1he hlgh-end value ls based on hlsLorlc lnflaLlon for medlcal
servlces ln new Lngland sLaLes, as measured by Lhe Consumer rlce lndex.
MM k|sk Iactor Impact on 1ota| Ma|neCare 8udget Cost: I|gure 63 shows how Lhe MM
growLh facLors would lmpacL Lhe LoLal cosL of expanslon. I|gures 64 and 6S summarlze poLenLlal
facLors and resulLs.

"#$%&' N?) *0*0 C#6D "1-.+& .+ U66%5'/ 0#//4' \14%'6
MM Growth k|sk Iactor
1.90 2.90 3.90
Summary 8ox 1
M|dd|e
LnrollmenL ln Sl? 2023-24 333,628 333,628 0 0.0 333,628 0 0.0
23.4 23.4 0.0 23.4 0.0
LnrollmenL ln Sl? 2023-24 376,429 376,429 0 0.0 376,429 0 0.0
26.9 26.9 0.0 26.9 0.0
LnrollmenL ln Sl? 2023-24 481,320 481,320 0 0.0 481,320 0 0.0
34.4 34.4 0.0 34.4 0.0
Summary 8ox 2
Low Lnd n|gh Lnd
8
a
s
e
|
|
n
e

1
8
a
s
e
|
|
n
e

2
L
x
p
a
n
s
|
o
n
MM k|sk Iactor Changes to Assumed M|dd|e Va|ues
"#$%&' N=) *0*0 >&+E.S C#6D "1-.+&

Summary 8ox 3
I
m
p
a
c
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t
o
8
a
s
e
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e

1
I
m
p
a
c
t

t
o
8
a
s
e
|
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n
e

2
Lxpans|on Impact of MM k|sk Iactors
"#$%&' NH) 29:136#+3 X5:1-. +7 *0*0 C#6D "1-.+&6

MM k|sk Iactor Impact on 1ota| Cost of Ma|neCare re|at|ve to 8ase||ne 1: 1hls charL provldes a
graphlc presenLaLlon on how Lhe LoLal cosLs can vary based on Lhe poLenLlal varlablllLy ln MM
growLh raLes. (See I|gure 66.)

54.0
52.6
54.4
54.8 54.8
5S.3
5S.9
52.S
53.0
53.S
54.0
54.S
5S.0
5S.S
56.0
2
0
1
1
-
1
2
2
0
1
2
-
1
3
2
0
1
3
-
1
4
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
2
1
2
0
2
1
-
2
2
2
0
2
2
-
2
3
2
0
2
3
-
2
4
8
|
|
|
|
o
n
s
State I|sca| ear
"#$%&' NN) *0*0 C#6D "1-.+& X5:1-. +3 01#3'I1&' @+.14 I+6. "+&'-16.;16'4#3' (

MM k|sk Iactor Impact on 1ota| Cost of Ma|neCare re|at|ve to 8ase||ne 2: 1hls charL provldes a
graphlc presenLaLlon on how Lhe LoLal cosLs can vary based on Lhe poLenLlal varlablllLy ln MM
growLh raLes. (See I|gure 67.)

"#$%&' NR) *0*0 C#6D "1-.+& X5:1-. +3 01#3'I1&' @+.14 I+6. "+&'-16.;16'4#3' 8
54.1
52.6
54.S
54.9
54.8
5S.3
5S.9
52.S
53.0
53.S
54.0
54.S
5S.0
5S.S
56.0
2
0
1
1
-
1
2
2
0
1
2
-
1
3
2
0
1
3
-
1
4
2
0
1
4
-
1
S
2
0
1
S
-
1
6
2
0
1
6
-
1
7
2
0
1
7
-
1
8
2
0
1
8
-
1
9
2
0
1
9
-
2
0
2
0
2
0
-
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8
|
|
|
|
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State I|sca| ear

MM k|sk Iactor Impact on 1ota| Cost of Lxpans|on ke|at|ve to 8ase||ne 1: 1hls charL provldes a
graphlc presenLaLlon on how Lhe LoLal cosLs of Lhe expanslon scenarlo can vary based on Lhe
poLenLlal varlablllLy ln MM growLh raLes. (See I|gure 68.)

"#$%&' NV) *0*0 C#6D "1-.+& X5:1-. +3 @+.14 I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' (
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State I|sca| ear
Low Lnd 10-ear Cost: 57 8||||on
n|gh Lnd 10-ear Cost: 58 8||||on

MM k|sk Iactor Impact on 1ota| Cost of Lxpans|on ke|at|ve to 8ase||ne 2: 1hls charL provldes a
graphlc presenLaLlon on how Lhe LoLal cosLs of Lhe expanslon scenarlo can vary based on Lhe

"#$%&' NW) *0*0 C#6D "1-.+& X5:1-. +3 @+.14 I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' 8

MM k|sk Iactor Impact on State Cost of Lxpans|on ke|at|ve to 8ase||ne 1: 1hls charL provldes a
graphlc presenLaLlon on how Lhe sLaLe cosLs of Lhe expanslon scenarlo can vary based on Lhe
poLenLlal varlablllLy ln MM growLh raLes. (See I|gure 70).

"#$%&' RA) *0*0 C#6D "1-.+& X5:1-. +3 K.1.' I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' (
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|
|
|
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State I|sca| ear
n|gh Lnd 10-ear Cost: 5894 M||||on

MM k|sk Iactor Impact on State Cost of Lxpans|on ke|at|ve to 8ase||ne 2: 1hls charL provldes a
graphlc presenLaLlon on how Lhe sLaLe cosLs of Lhe expanslon scenarlo can vary based on Lhe

"#$%&' R() *0*0 C#6D "1-.+& X5:1-. +3 K.1.' I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' 8

l|vate Loo 8|s| lacto
1he Lhlrd rlsk facLor consldered ls Lhe number of persons wlLh lncomes below Lhe ACA Lhresholds
currenLly covered by healLh lnsurance who would become ellglble for MalneCare lf Lhey would lose
Lhelr prlvaLe healLhcare coverage. 1he percenLages below are Lhe facLors used Lo deLermlne Lhe
number of Lhose persons who would ulLlmaLely slgn up for MalneCare. 1he meLhodology for how
Lhese facLors were chosen ls dlscussed ln more deLall ln Append|x 8. I|gures 72, 73, and 74
summarlze poLenLlal facLors and resulLs.

"#$%&' R8) <&+::'/ *&#P1.' X36%&13-' C#6D "1-.+&
Coverage 1ype Low Lnd M|dd|e n|gh Lnd
non-group 24.0 30.8 34.0
Lmployer-based 80.2 93.0 98.0
Dropped r|vate Insurance k|sk Iactor
Summary 8ox 1
M|dd|e
LnrollmenL ln Sl? 2023-24 333,628 333,628 0 0.0 333,628 0 0.0
23.4 23.4 0.0 23.4 0.0
10 ?ear 1oLal CosL (Mllllons $) 34,784.9 34,784.9 - 0.0 34,784.9 - 0.0
10 ?ear SLaLe CosL (Mllllons $) 13,797.7 13,797.7 - 0.0 13,797.7 - 0.0
LnrollmenL ln Sl? 2023-24 376,429 376,429 0 0.0 376,429 0 0.0
26.9 26.9 0.0 26.9 0.0
10 ?ear SLaLe CosL (Mllllons $) 14,081.9 14,081.9 - 0.0 14,081.9 - 0.0
LnrollmenL ln Sl? 2023-24 481,320 473,438 -8,062 -1.7 301,633 20,133 4.2
34.4 33.9 -0.6 33.9 1.4
10 ?ear 1oLal CosL (Mllllons $) 42,229.2 41,748.4 (480.8) -1.1 43,373.3 1,144.1 2.7
Summary 8ox 2
Low Lnd n|gh Lnd
8
a
s
e
|
|
n
e

1
8
a
s
e
|
|
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e

2
L
x
p
a
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s
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n
r|vate Drop k|sk Iactor Changes to Assumed M|dd|e Va|ues
"#$%&' R=) *&#P1.' <&+: C#6D "1-.+& IS13$'6 .+ U66%5'/ 0#//4' \14%'6

"#$%&' R?) 29:136#+3 X5:1-. +7 *&#P1.' <&+: C#6D "1-.+&6
Summary 8ox 3
I
m
p
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t

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o
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a
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e
|
|
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e

1
I
m
p
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2
Lxpans|on Impact of r|vate Drop k|sk Iactors

r|vate Drop k|sk Iactor Impact on Lnro||ment ke|at|ve to 8ase||ne 1: I|gure 7S shows Lhe lmpacL
on enrollmenL based on facLors esLlmaLlng Lhe number of persons under 138 of lL who would
lose prlvaLe lnsurance and consequenLly enroll ln MalneCare.

3SS,628
281,147
481,S20
32S,384
3SS,628
444,739
S33,984
2S0,000
300,000
3S0,000
400,000
4S0,000
S00,000
SS0,000
2
0
1
1
-
1
2
2
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C
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L
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t
State I|sca| ear
1
Iorecast
noLe:
1
lncludes only
"#$%&' RH) *&#P1.' <&+: C#6D "1-.+& X5:1-. +3 23&+445'3. C'41.#P' .+ ;16'4#3' (

r|vate Drop k|sk Iactor Impact on Lnro||ment ke|at|ve to 8ase||ne 2: I|gure 76 shows Lhe lmpacL
on enrollmenL based on facLors esLlmaLlng Lhe number of persons under 138 of lL who would
lose prlvaLe lnsurance and consequenLly enroll ln MalneCare.

"#$%&' RN) *&#P1.' <&+: C#6D "1-.+& X5:1-. +3 23&+445'3. C'41.#P' .+ ;16'4#3' 8
376,429
281,147
481,S20
32S,384
376,429
444,739
S33,984
2S0,000
300,000
3S0,000
400,000
4S0,000
S00,000
SS0,000
2
0
1
1
-
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1
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noLe:
1
lncludes only

r|vate Drop k|sk Iactor Impact on Ma|neCare as a ercent of State opu|at|on: I|gure 77 shows
Lhe lmpacL on Lhe percenL of persons enrolled ln MalneCare as a percenLage of Lhe overall
populaLlon based on facLors esLlmaLlng Lhe number of persons under 138 of lL who would lose
prlvaLe lnsurance and consequenLly enroll ln MalneCare.

27.7
33.9
22.6
28.2
34.4
29.4
3S.9
0.0
S.0
10.0
1S.0
20.0
2S.0
30.0
3S.0
40.0
Ma|neCare
1
noLe:
1
lncludes only
"#$%&' RR) ltlvote utop klsk loctot lmpoct oo Moloecote os o letceot of 5tote lopolotloo

r|vate Drop k|sk Iactor Impact on 1ota| Cost of Ma|neCare re|at|ve to both 8ase||nes: 1hls charL
Lhe prlvaLe drop raLes. (See I|gure 78.)

52.6
54.S
5S.3
5S.3
5S.S
54.4
52.S
53.0
53.S
54.0
54.S
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"#$%&' RV) *&#P1.' <&+: C#6D "1-.+& X5:1-. +3 @+.14 I+6. +7 01#3'I1&' &'41.#P' .+ L+.S ;16'4#3'6

r|vate Drop k|sk Iactor Impact on 1ota| Cost of Lxpans|on ke|at|ve to 8ase||ne 1: I|gure 79 shows
Lhe lmpacL on Lhe LoLal cosL of expanslon based on varylng Lhe esLlmaLes of Lhe number of persons
under 138 of lL who would lose prlvaLe lnsurance and subsequenLly enroll ln MalneCare.

"#$%&' RW) *&#P1.' <&+: C#6D "1-.+& X5:1-. +3 @+.14 I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' (
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Low Lnd 10-ear Cost: 57 8||||on

r|vate Drop k|sk Iactor Impact on 1ota| Cost of Lxpans|on ke|at|ve to 8ase||ne 2: I|gure 80 shows
Lhe lmpacL on Lhe LoLal cosL of expanslon based on varylng Lhe esLlmaLes of Lhe number of persons

"#$%&' VA) *&#P1.' <&+: C#6D "1-.+& X5:1-. +3 @+.14 I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' 8
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|
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State I|sca| ear

r|vate Drop k|sk Iactor Impact on State Cost of Lxpans|on ke|at|ve to 8ase||ne 1: I|gure 81 shows
Lhe lmpacL on Lhe sLaLe cosL of expanslon based on varylng Lhe esLlmaLes of Lhe number of persons

"#$%&' V() *&#P1.' <&+: C#6D "1-.+& X5:1-. +3 K.1.' I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' (
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|
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State I|sca| ear
n|gh Lnd 10-ear Cost: 594S M||||on

r|vate Drop k|sk Iactor Impact on State Cost of Lxpans|on ke|at|ve to 8ase||ne 2: I|gure 82 shows
Lhe lmpacL on Lhe sLaLe cosL of expanslon based on varylng Lhe esLlmaLes of Lhe number of persons

"#$%&' V8) *&#P1.' <&+: C#6D "1-.+& X5:1-. +3 K.1.' I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' 8)

lMAl 8|s| lacto
lMA conLlnues Lo be a rlsk facLor. 1he low-end values assume Lhe hlghesL regular lMA raLe Malne
recelved ln Lhe pasL LwenLy years ln Sl? 2016-17. 1he hlgh-end value assumes LhaL Lhe flscal crlsls
of Lhe federal governmenL causes Congress Lo reduce Lhe enhanced lMA raLes Lo Lhe currenL
regular lMA. I|gures 83, 84, and 8S summarlze poLenLlal facLors and resulLs.

"#$%&' V=) "0U* C#6D "1-.+&6
IMA Category Low Lnd M|dd|e n|gh Lnd
8egular 66.38 61.33 61.33
CPl 96.09 96.09 61.33
Lnhanced 90.00 90.00 61.33
IMA k|sk Iactor
kates |n the Cut ears
Summary 8ox 1
M|dd|e
LnrollmenL ln Sl? 2023-24 333,628 333,628 0 0.0 333,628 0 0.0
23.4 23.4 0.0 23.4 0.0
10 ?ear SLaLe CosL (Mllllons $) 13,797.7 12,327.6 (1,270.1) -9.2 14,030.8 233.1 1.7
LnrollmenL ln Sl? 2023-24 376,429 376,429 0 0.0 376,429 0 0.0
26.9 26.9 0.0 26.9 0.0
10 ?ear SLaLe CosL (Mllllons $) 14,081.9 12,780.6 (1,301.3) -9.2 14,313.0 233.1 1.7
LnrollmenL ln Sl? 2023-24 481,320 481,320 0 0.0 481,320 0 0.0
34.4 34.4 0.0 34.4 0.0
10 ?ear SLaLe CosL (Mllllons $) 14,629.4 13,313.6 (1,313.8) -9.0 16,301.7 1,872.3 12.8
Summary 8ox 2
Low Lnd n|gh Lnd
8
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IMA k|sk Iactor Changes to Assumed M|dd|e Va|ues
"#$%&' V?) "0U* C#6D "1-.+& IS13$'6 .+ U66%5'/ +7 0#//4' \14%'6

"#$%&' VH) 29:136#+3 X5:1-. +7 "0U* C#6D "1-.+&6
AddlLlonal 10 ?ear SLaLe CosL (Mllllons $) 788.0 6.3 831.7 6.0 2,471 17.6
AddlLlonal 10 ?ear SLaLe CosL (Mllllons $) 333.0 4.2 347.4 3.9 2,186.6 13.3
I
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Lxpans|on Impact of IMA k|sk Iactors
Summary 8ox 3

IMA k|sk Iactor Impact on State Cost of Lxpans|on ke|at|ve to 8ase||ne 1: I|gure 86 summarlzes
Lhe sLaLe cosL based on Lhe lMA rlsks.

"#$%&' VN) "0U* C#6D "1-.+& X5:1-. K.1.' I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' (
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51S0
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52S0
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State I|sca| ear
n|gh Lnd 10-ear Cost: 52.S 8||||on

IMA k|sk Iactor Impact on State Cost of Lxpans|on ke|at|ve to 8ase||ne 2: I|gure 87 summarlzes
Lhe sLaLe cosL based on Lhe lMA rlsks.

"#$%&' VR) "0U* C#6D "1-.+& X5:1-. K.1.' I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' 8

uest Case / vost Case Scena|os
1he besL case scenarlo and worsL case scenarlo assume LhaL Lhree of Lhe four rlsk facLors occur for
each Lhe low-end and hlgh-end scenarlos. I|gure 88 summarlzes Lhe rlsk facLors assumed by Lhese
scenarlos. I|gures 89 and 90 summarlze poLenLlal facLors and resulLs.

1he besL case scenarlo assumes Lhe followlng Lhree rlsk facLors: Lhe poverLy raLe does noL grow as
rapldly as expecLed, Lhe MM cosL rlses more slowly, and a smaller number of persons currenLly
covered by prlvaLe healLh lnsurance wlLh lncomes aL or below 138 of lL wlll lose Lhelr healLh
coverage.
1he worsL case scenarlo assumes Lhe followlng Lhree rlsk facLors: MM cosLs rlse more sharply,
lMA raLes are reduced more drasLlcally Lhan anLlclpaLed, and a smaller number of persons
currenLly covered by prlvaLe healLh lnsurance wlLh lncomes aL or below 138 of lL wlll lose Lhelr
healLh coverage.

"#$%&' VV) ;'6. 13/ F+&6. I16' K-'31&#+6
k|sk Iactor 8est Case Worst Case
overLy CrowLh Consldered LeasL Llkely
MM Consldered Consldered
rlvaLe urop Consldered Consldered
lMA LeasL Llkely Consldered
8est Case]Worst Case Scenar|os
1hree out of Iour Come 1rue
Summary 8ox 1

AddlLlonal 10 ?ear SLaLe CosL (Mllllons $) 707.1 3.6 831.7 6.0 3,069 20.7
AddlLlonal 10 ?ear SLaLe CosL (Mllllons $) 432.2 3.3 347.4 3.9 2,763.4 18.2
I
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Lxpans|on Impact of 8est Case and Worst Case k|sk Iactors
Summary 8ox 3
M|dd|e
LnrollmenL ln Sl? 2023-24 333,628 331,372 -24,236 -6.8 333,628 0 0.0
23.4 23.7 -1.7 23.4 0.0
LnrollmenL ln Sl? 2023-24 376,429 330,829 -23,399 -6.8 376,429 0 0.0
26.9 23.1 -1.8 26.9 0.0
LnrollmenL ln Sl? 2023-24 481,320 442,610 -38,910 -8.1 301,633 20,133 4.2
34.4 31.7 -2.8 33.9 1.4
Summary 8ox 2
Low Lnd n|gh Lnd
8
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8est Case and Worst Case k|sk Iactor Changes to Assumed M|dd|e Va|ues
"#$%&' WA) 29:136#+3 X5:1-. +7 ;'6. I16' 13/ F+&6. I16' C#6D "1-.+&6
"#$%&' VW) ;'6. 13/ F+&6. I16' C#6D "1-.+& IS13$'6 .+ U66%5'/ 0#//4' \14%'6

8est Case ] Worst Case k|sk Iactor Impact on Lnro||ment ke|at|ve to 8ase||ne 1: I|gure 91 shows
how MalneCare enrollmenL would change based on Lhe besL case and worsL case scenarlos.

"#$%&' W() ;'6. I16' M F+&6. I16' C#6D "1-.+& X5:1-. +3 23&+445'3. C'41.#P' .+ ;16'4#3' (
281,147
481,S20
32S,384
3SS,628
444,739
S33,984
2S0,000
300,000
3S0,000
400,000
4S0,000
S00,000
SS0,000
2
0
1
1
-
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2
2
0
1
2
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2
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State I|sca| ear
1
Iorecast
noLe:
1
lncludes only

8est Case ] Worst Case k|sk Iactor Impact on Lnro||ment ke|at|ve to 8ase||ne 2: I|gure 92 shows
how MalneCare enrollmenL would change based on Lhe besL case and worsL case scenarlos.

376,429
281,147
481,S20
32S,384
444,739
S33,984
2S0,000
300,000
3S0,000
400,000
4S0,000
S00,000
SS0,000
2
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1
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"#$%&' W8) ;'6. I16' M F+&6. I16' C#6D "1-.+& X5:1-. +3 23&+445'3. C'41.#P' .+ ;16'4#3' 8

8est Case ] Worst Case k|sk Iactor Impact on Ma|neCare as a ercent of State opu|at|on: I|gure
93 shows how MalneCare enrollmenL as a percenL of Lhe overall populaLlon would change based on
Lhe besL case and worsL case scenarlos. ln Lhe besL case scenarlo, 31.7 of Lhe populaLlon would
be on MalneCare by Sl? 2022-23. ln Lhe worsL case scenarlo, lL would be 33.9

"#$%&' W=) ;'6. I16' M F+&6. I16' C#6D "1-.+& X5:1-. +3 01#3'I1&' 16 1 *'&-'3. +7 K.1.' *+:%41.#+3
27.4
31.7
22.6
28.2
34.4
29.4
3S.9
0.0
S.0
10.0
1S.0
20.0
2S.0
30.0
3S.0
40.0
Ma|neCare
1
noLe:
1
lncludes only

8est Case ] Worst Case k|sk Iactor Impact on 1ota| Cost of Ma|neCare re|at|ve to 8ase||ne 1: 1hls
charL provldes a graphlc presenLaLlon on how Lhe LoLal cosLs can vary based on Lhe besL case and
worsL case scenarlos. (See I|gure 94.)

"#$%&' W?) ;'6. I16' M F+&6. I16' C#6D "1-.+& X5:1-. +3 @+.14 I+6. +7 01#3'I1&' &'41.#P' .+ ;16'4#3' (
53.7
52.6
54.4
54.8
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5S.3
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54.0
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State I|sca| ear

8est Case ] Worst Case k|sk Iactor Impact on 1ota| Cost of Ma|neCare re|at|ve to 8ase||ne 2: 1hls
charL provldes a graphlc presenLaLlon on how Lhe LoLal cosLs can vary based on Lhe besL case and
worsL case scenarlos. (See I|gure 9S.)

53.8
52.6
54.S
54.9
54.S
5S.3
56.0
52.S
53.0
53.S
54.0
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"#$%&' WH) ;'6. I16' M F+&6. I16' C#6D "1-.+& X5:1-. +3 @+.14 I+6. +7 01#3'I1&' &'41.#P' .+ ;16'4#3' 8

8est Case ] Worst Case k|sk Iactor Impact on 1ota| Cost of Lxpans|on ke|at|ve to 8ase||ne 1: I|gure
96 shows how LoLal cosLs for MalneCare would change based on Lhe besL case and worsL case
scenarlos.

"#$%&' WN) ;'6. I16' M F+&6. I16' C#6D "1-.+& X5:1-. +3 @+.14 I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' (
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State I|sca| ear

8est Case ] Worst Case k|sk Iactor Impact on 1ota| Cost of Lxpans|on ke|at|ve to 8ase||ne 2: I|gure
97 shows how LoLal cosLs for MalneCare would change based on Lhe besL case and worsL case
scenarlos.

"#$%&' WR) ;'6. I16' M F+&6. I16' C#6D "1-.+& X5:1-. +3 @+.14 I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' 8
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2
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State I|sca| ear
Low Lnd 10-ear Cost: 5S.7 8||||on

8est Case ] Worst Case k|sk Iactor Impact on State Cost of Lxpans|on ke|at|ve to 8ase||ne 1: I|gure
98 shows how sLaLe cosLs of expanslon for MalneCare would change based on Lhe besL case and
worsL case scenarlos. As can be seen Lhey are radlcally dlfferenL. under Lhe besL case scenarlo,
Malne sLlll has a cosL of $707 mllllon over Len years. under Lhe worsL case scenarlo, Lhe cosL would
be $3.1 bllllon over Len years.

"#$%&' WV) ;'6. I16' M F+&6. I16' C#6D "1-.+& X5:1-. +3 K.1.' I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' (

8est Case ] Worst Case k|sk Iactor Impact on State Cost of Lxpans|on ke|at|ve to 8ase||ne 2: I|gure
99 shows how sLaLe cosLs of expanslon for MalneCare would change based on Lhe besL case and
worsL case scenarlos. As can be seen Lhey are radlcally dlfferenL. under Lhe besL case scenarlo,
Malne sLlll has a cosL of $432 mllllon over Len years. under Lhe worsL case scenarlo, Lhe cosL would
be $2.8 bllllon over Len years.

"#$%&' WW) ;'6. I16' M F+&6. I16' C#6D "1-.+& X5:1-. +3 K.1.' I+6. +7 29:136#+3 C'41.#P' .+ ;16'4#3' 8


Sect|on VII: Conc|us|on and Next Steps

Sect|on vll: Conc|us|on ano lext Steos
As Lhls reporL reveals, expandlng Lhe Medlcald program ln Malne lnvolves flscal, operaLlonal and
quanLlLaLlve lssues. 1he AC llnanclal Model demonsLraLes LhaL lL wlll be challenglng for Malne Lo
afford MalneCare ln Lhe fuLure even wlLhouL expanslon. Clven currenL Lrends, MalneCare wlll
comprise larger shares of Maines General Fund budgets, which will grow from 24.2% of the General
Fund budget to 33.9% to 34.9% in ten years. The states poverty growth rate is one causal factor
drlvlng Lhe dlfference beLween Lhe sLaLe cosL for MalneCare and Lhe resL of Lhe sLaLe budgeL.
Lxpandlng ellglblllLy wlll only exacerbaLe Lhe Lrend, whereby MalneCare wlll comprlse 36.4 of Lhe
Ceneral lund budgeL ln Len years.
ln addlLlon, Lhe rlsk analysls ln Sect|on VI shows LhaL ln Lhe besL-case scenarlo, expanslon of
Medlcald ellglblllLy would sLlll cosL Lhe sLaLe $432 mllllon Lo $707 mllllon over Lhe nexL Len years,
dependlng on Lhe basellne used for comparlson. lf parenLs wlLh lncomes beLween 101 of lL and
138 of lL are lncluded ln Lhe basellne, Lhe cosL would be $432 mllllon. lf Lhey are excluded from
Lhe basellne, Lhe cosL would reach $707 mllllon. Powever, Lhe worsL-case scenarlo would cosL Lhe
sLaLe beLween $2.8 bllllon Lo $3.1 bllllon over Lhe nexL Len years, dependlng agaln on Lhe basellnes
used for comparlson.
1he quallLaLlve lssues are no less challenglng. ConslsLenL wlLh naLlonal Medlcald Lrends,
performance measures lndlcaLe LhaL Lhe quallLy of care provlded by MalneCare does noL maLch
whaL ls avallable elsewhere, lncludlng commerclally avallable lnsurance. Lxpandlng MalneCare does
noL address any of Lhese quallLy-of-care lssues, moreover, expanslon may leave Lhose loslng
commerclal coverage wlLh no oLher cholce buL Lo enroll ln MalneCare. Lxpanslon wlll also dlverL
resources from addresslng serlous program-lnLegrlLy lssues Lo proLecL Lhe program agalnsL wasLe,
abuse, and fraud. llnally, as MalneCare has walLlng llsLs of persons currenLly needlng speclallzed
servlces, expanslon wlll noL provlde needed servlces Lo Lhese lndlvlduals buL wlll allow oLher persons
Lo be covered who are less vulnerable Lhan Lhose on Lhe walLlng llsLs.
1he more presslng needs are resLrucLurlng and sLreamllnlng Lo make MalneCare more efflclenL and
Lo dellver beLLer quallLy ouLcomes. As ln mosL sLaLes, over Llme, Lhe sysLem has been so expanded
and changed ln a plecemeal manner LhaL lL has become uncoordlnaLed, dlfflculL for many Lo
navlgaLe, lacklng ln key program-lnLegrlLy safeguards, and exhlblLlng cosL facLors LhaL exceed Lhe
growLh of Lhe resL of Lhe Ceneral lund budgeL. Lxpandlng MalneCare aL Lhe currenL Llme wlll llkely
dlverL resources away from reform efforLs necessary Lo address Lhese presslng lssues and Lo
lmprove Lhe program.
Sect|on VII: Conc|us|on and Next Steps

PealLh-care access and lmproved healLh ouLcomes remaln a necesslLy. Lxpanslon of Medlcald aL Lhe
presenL Llme however, may noL be Lhe besL pollcy cholce Lo aLLaln Lhose goals. CLher vlable
alLernaLlves may allow Malne Lo lmprove access and quallLy whlle prlorlLlzlng needs and savlng Lax
dollars. ConsequenLly, Malne needs a sLaLe-based soluLlon wlLh flexlblllLy from Lhe federal
governmenL LhaL focuses on access, Lransparency, quallLy, personal responslblllLy, and efflclency.
1haL klnd of alLernaLlve would llkely offer execuLlve and leglslaLlve pollcymakers greaLer budgeLary
cerLalnLy and allow Lhem Lo focus on oLher flscal and pollcy prlorlLles.

Append|x A
Aooeno|x A: Summay o Meo|ca|o-Lxoans|on Lec|s|ons by t|e States
S1A1LS lC1 LxlAlLllC MLLlCAlL (21 S1A1LS)
State Governor Leg|s|ature Comment
ALA8AMA 8enLley (8) CC conLrols boLh houses of
leglslaLure.
SLaLe noL seeklng expanslon of Medlcald program.
ALASkA arnell (8) CC conLrols boLh houses of
leglslaLure.
SLaLe noL seeklng expanslon of Medlcald program. ln
March 2013 uemocraLlc 8epresenLaLlve lnLroduced
resoluLlon Lo compel governor Lo Lake acLlon buL
resoluLlon dld noL galn LracLlon among lawmakers.
lLC8luA ScoLL (8) CC conLrols boLh houses of
leglslaLure.
CLC8ClA ueal (8) CC conLrols boLh houses of
leglslaLure.
Powever, lL dld creaLe commlLLee Lo conslder exlsLlng
program reform.
luAPC CLLer (8) CC conLrols boLh houses of
leglslaLure.
lnulAnA ence (8) CC conLrols boLh houses of
leglslaLure.
SLaLe noL seeklng expanslon of Medlcald rogram. ln
SepLember 2013, lndlana flnallzed a deal exLendlng
plloL program whlch resembles healLh savlngs
accounLs.
Append|x A
kAnSAS 8rownback (8) CC conLrols boLh houses of
leglslaLure.
LCulSlAnA !lndal (8) CC conLrols boLh houses of
leglslaLure.
MAlnL Leage (8) uemocraLs conLrol boLh
houses of leglslaLure.
Governor vetoed a bill to expand states Medicaid
rogram. Pouse lawmakers falled Lo galn Lwo-Lhlrd
ma[orlLy necessary Lo overrlde veLo.
MlSSlSSll 8ryanL (8) CC conLrols boLh houses of
leglslaLure.
MCn1AnA 8ullock (u) CC conLrols boLh houses of
leglslaLure.
nL88ASkA Pelneman (8) unlcameral leglslaLure ls
nonparLlsan.
nLW PAMSPl8L Passan (u) uemocraLs conLrol Pouse, CC
conLrols SenaLe
nP voLed agalnsL expanslon on november 22.
nC81P CA8CLlnA Mc8ory (8) CC conLrols boLh houses of
leglslaLure.
CkLAPCMA lallln (8) CC conLrols boLh houses of
leglslaLure.
SLaLe noL currenLly seeklng expanslon of Medlcald
program. Few have stated governor has not closed
the door on future plans.
Append|x A
SCu1P CA8CLlnA Paley (8) CC conLrols boLh houses of
leglslaLure.
SLaLe has allocaLed elghLy mllllon Lo hosplLal lncenLlve
paymenL program.
SCu1P uAkC1A uaugaard (8) CC conLrols boLh houses of
leglslaLure.
program.
1LnnLSSLL Paslam (8) CC conLrols boLh houses of
leglslaLure.
program.
1LxAS erry (8) CC conLrols boLh houses of
leglslaLure.
vl8ClnlA Mcuonnell (8) CC conLrols house, makeup
of SenaLe for 2014 ls unclear.
Covernor-elecL McAullffe (u) supporLs expanslon.
Powever, Ceneral Assembly ls llsLed ln opposlLlon Lo
seeklng expanslon of Medlcald program...
WlSCCnSln Walker (8) CC conLrols boLh houses of
leglslaLure.
W?CMlnC Mead (8) CC conLrols boLh houses of
leglslaLure.

S1A1LS CClSlLL8llC LxlAlSlCl (4 S1A1LS)
Append|x A
MlSSCu8l nlxon (u) CC conLrols boLh houses of
leglslaLure.
Covernor supporLs expanslon however Ceneral
Assembly dld noL lnclude fundlng for expanslon ln 2013
budgeL. Mlssourl Pouse lnLerlm CommlLLee on
Medlcald 1ransformaLlon held hearlng Lo dlscuss
varlous opLlons lncludlng model slmllar Lo Arkansas.
Powever, leglslaLlon Lo expand program wlll noL be
consldered unLll 2014 sesslon.
LnnS?LvAnlA CorbeLL (8) CC conLrols boLh houses of
leglslaLure.
Governors proposed premium-asslsLance plan would
help low-lncome persons wlLh federal subsldlzes
Lhrough Lhe federal exchange and use Medlcald
expanslon funds Lo help ellglble reclplenLs buy prlvaLe
healLh plans. Ceneral Assembly has noL approved
measures whlch would also requlre approval from
federal governmenL. 1here have been dlscusslons by
Lhe execuLlve branch LhaL sLaLe leglslaLlve approval
would noL be necessary.
u1AP PerberL (8) CC conLrols boLh houses of
leglslaLure.
Governor seeking a Utah solution to expansion.
SLaLe has puL LogeLher leglslaLlve Lask force and work
group Lo conslder opLlons.

S1A1LS LxlAlLllC MLLlCAlL (2S states ano L.C.)
Append|x A
A8lZCnA 8rewer (8) CC conLrols boLh
Slgned lnLo law durlng Speclal sesslon !une 2013, plan Lo
cover approxlmaLely 300,000 ellglble resldenLs.
A8kAnSAS 8eebe (u) CC conLrols boLh
uslng Medlcald expanslon money Lo purchase prlvaLe
lnsurance for abouL 230,000 ellglble resldenLs.
CALllC8nlA 8rown (u) uemocraLs conLrol boLh
Slgned lnLo law !une 2013, plan Lo cover approxlmaLely
1.4 mllllon resldenLs under sLaLes Medl-Cal program.
CCLC8AuC Plckenlooper (u) uemocraLs conLrol boLh
Slgned lnLo law May 2013, plan Lo cover an addlLlonal
160,000 adulLs.
CCnnLC1lCu1 Malloy (u) uemocraLs conLrol boLh
Cne of flve sLaLes LhaL opLed Lo expand early
uLLAWA8L Markell (u) uemocraLs conLrol boLh
Approved 29.8 million in July 2013 to fund the States
Medicaid commitment.
u.C. Cray (u) uemocraLs conLrol clLy
councll.
SoughL permlsslon from federal governmenL Lo expand
Medlcald Lo addlLlonal 33,000 resldenLs.
PAWAll Abercromble (u) uemocraLs conLrol boLh

lLLlnClS Culnn (u) uemocraLs conLrol boLh
Slgned lnLo law !uly 2013, plan Lo cover an addlLlonal
342,000 resldenLs.
lCWA 8ransLad (8) CC conLrols Pouse,
uemocraLs conLrol
lan, whlch provldes lnsurance subsldles, buL noL
Medlcald, Lo households beLween 101 and 138 of
Append|x A
SenaLe. lL, yeL Lo be approved by feds.
kLn1uCk? 8eshear (u) uemocraLs conLrol
Pouse, CC conLrols
SenaLe.
SepL. 3, 2013 federal [udge ruled LhaL Lhe governor has
Lhe auLhorlLy Lo expand Medlcald and esLabllsh an
lnsurance exchange.
MA8?LAnu OMalley (D) uemocraLs conLrol boLh
Slgned lnLo law May 2013 blll Lo fully lmplemenL
Affordable Care AcL.
MASSACPuSL11S aLrlck (u) uemocraLs conLrol boLh
!uly 2013, slgned lnLo law sLaLe Sl? 2014 sLaLe budgeL
wlLh supporL full lmplemenLaLlon of affordable care acL.
MlCPlCAn Snyder (8) CC conLrols boLh
Slgned lnLo law SepL. 2013 expanslon of Medlcald
program beglnnlng Aprll 2014. lan conLalns cosL-
sharlng provlslons LhaL requlre approval from federal
governmenL.
MlnnLSC1A uayLon (u) uemocraLs conLrol boLh
Slgned lnLo law lebruary 2013 law expandlng Medlcald
Lo approxlmaLely 33,000 chlldless, low-lncome adulLs.
nLvAuA Sandoval (8) uemocraLs conLrol boLh
uecember 2012 verbally commlLLed Lo expandlng
Medlcald Lo approxlmaLely 78,000 resldenLs.
nLW !L8SL? ChrlsLle (8) uemocraLs conLrol boLh
Slgned sLaLe budgeL LhaL lncludes $227 mllllon for
expanslon buL Covernor veLoed leglslaLlon Lo make
expanslon permanenL.
nLW MLxlCC MarLlnez (8) uemocraLs conLrol boLh
Announced ln !anuary 2013 sLaLe would parLlclpaLe ln
Medlcald expanslon.
Append|x A
nLW ?C8k Cuomo (u) uemocraLs conLrol
Pouse, CC conLrols
SenaLe.
!une 2012 announcemenL LhaL sLaLe would parLlclpaLe ln
expanslon.
nC81P uAkC1A ualrymple (8) CC conLrols boLh
Slgned leglslaLlon Aprll 2013 expandlng Medlcald ln
sLaLe.
CPlC kaslch (8) CC conLrols boLh
SLaLes ConLrolllng board (speclal leglslaLlve panel)
approved 3-2 voLe Lo expand. Powever, leglslaLors have
pledged Lo mounL legal campalgn agalnsL expanslon.
C8LCCn klLzhaber (u) uemocraLs conLrol boLh
SLaLe approved expanslon up Lo 138 of lL of all
resldenLs.
8PCuL lSLAnu Chafee (l) uemocraLs conLrol boLh
!uly 2013 slgned flscal year 2014 budgeL whlch lncluded
plan Lo expand Medlcald.
vL8MCn1 Shumlln (u) uemocraLs conLrol boLh
SLaLe approved expanslon plan Lo cover approxlmaLely
an addlLlonal 47,000 sLaLe resldenLs.
WASPlnC1Cn lnslee (u) uemocraLs conLrol boLh
!une 2013 slgned sLaLe budgeL Lo expand Medlcald ln
Lhe sLaLe.
WLS1 vl8ClnlA 1omblln (u) uemocraLs conLrol boLh
May 2013 announced sLaLe would exLend coverage Lo
approxlmaLely an addlLlonal 91,300 sLaLe resldenLs.

Append|x A
MLLlCAlL LxlAlSlCl u? S1A1L lA81? CCl18CL
kepub||can Governor Democrat|c Governor Independent
noL Lxpandlng Alabama, Alaska, llorlda, Ceorgla, ldaho,
lndlana, kansas, Loulslana, Malne,
Mlsslsslppl, nebraska, norLh Carollna,
Cklahoma, SouLh Carollna, SouLh uakoLa,
1ennessee, 1exas, vlrglnla, Wlsconsln,
and Wyomlng
MonLana and new Pampshlre
Conslderlng
Lxpandlng
ennsylvanla and uLah Mlssourl
Lxpandlng Arlzona, lowa, Mlchlgan, nevada, new
!ersey, new Mexlco, norLh uakoLa, Chlo
Arkansas, Callfornla, Colorado,
ConnecLlcuL, uelaware, u.C., Pawall,
llllnols, kenLucky, Maryland,
MassachuseLLs, MlnnesoLa, new ?ork,
Cregon, vermonL, WashlngLon, and WesL
vlrglnla
8hode lsland

kepub||can Leg|s|ature Democrat|c Leg|s|ature Sp||t Leg|s|ature or Cther
noL Lxpandlng Alabama, Alaska, llorlda, Ceorgla,
ldaho, lndlana, kansas, Loulslana,
Malne, Mlsslsslppl, MonLana, norLh
Carollna, Cklahoma, SouLh Carollna,
Malne nebraska and new
Pampshlre
Append|x A
SouLh uakoLa, 1ennessee, 1exas,
vlrglnla, Wlsconsln, and Wyomlng
Conslderlng
Lxpandlng
Mlssourl, ennsylvanla, and uLah
Lxpandlng Arlzona, Arkansas, Mlchlgan, norLh
uakoLa, Chlo,
Callfornla, Colorado,
ConnecLlcuL, uelaware, u.C.,
Pawall, llllnols, Maryland,
MassachuseLLs, MlnnesoLa,
nevada, new !ersey, new
Mexlco, Cregon, 8hode lsland,
vermonL, WashlngLon, and WesL
vlrglnla
lowa, kenLucky, and new
?ork
Sources: hLLp://www.advlsory.com/ually-8rleflng/8esources/rlmers/MedlcaldMap#llghLbox/3/

Append|x A


Append|x 8
Aooeno|x u: Met|ooo|ogy, Assumot|ons, Lata, ano Ct|e 1ec|n|ca|
lnomat|on
Cvev|ew
1he flnanclal model used for Lhls sLudy was speclflcally developed and cusLomlzed by 1he Alexander
Croup for Lhe SLaLe of Malne. 8ecause each sLaLe ls dlfferenL, lL ls necessary Lo Lallor a model Lo Lhe
speclflc demographlcs of a sLaLe as well as Lhe unlque characLerlsLlcs of lLs Medlcald program. no
Lwo sLaLes are allke, and more generlc models mlss Lhese nuances LhaL produce less speclflc resulLs.
1here are numerous assumpLlons and daLa sources LhaL were uLlllzed ln generaLlng Lhe basellne
scenarlos and Lhe LesL case. 1hls appendlx summarlzes Lhe more lmporLanL ones.
loou|at|on Couos
lor purposes of Lhe flnanclal model, only Lhose enrollees wlLh full membershlp were lncluded. All
persons wlLhouL full beneflLs, such as low-lncome Medlcare buy-ln groups who meeL Lhe crlLerla for
parLlclpaLlon ln urugs for Llderly (uLL) program and/ or Malne 8x were excluded ln Lhe forecasL.
1he followlng populaLlons groups were ldenLlfled for use ln Lhe model:
Group A
1radlLlonal MalneCare Ma[or caLegorles:
! Aged
! 8llnd/ulsabled
! Chlldren wlLh lncomes up Lo 100 of lL
! arenLs wlLh lncomes up Lo 100 of lL
! regnancy
! SLaLe only
! CLher
Chlldren on CPl wlLh lncomes 101 Lo 138 of lL
Chlldren on CPl wlLh lncomes 139 Lo 200 of lL
arenLs wlLh lncomes beLween 101 and 138 of lL
Chlldless adulLs covered under Lhe chlldless adulL walver
losLer chlldren beLween Lhe ages of 19 and 23
Group 8
Children woodwork effect
Parents woodwork effect
Group C
CLher chlldless adulLs noL covered under Lhe walver wlLh lncomes up Lo 138 of lL
Append|x 8
Group D
Chlldren covered by prlvaLe lnsurance wlLh lncomes up Lhrough 200 of lL
arenLs covered by prlvaLe lnsurance wlLh lncomes up Lhrough 138 of lL

Group A are Lhose caLegorles for whlch MuPPS was able Lo produce populaLlon daLa from lnLernal
daLabase sysLems.
Group 8 are Lhe woodwork-effecL populaLlons. ln Lhese cases, populaLlon esLlmaLes were creaLed
by mulLlplylng 2011 CurrenL opulaLlon Survey (CS) daLa esLlmaLes lssued by Lhe u.S. Census
8ureau on Lhe number of chlldren and parenLs currenLly ellglble for Medlcald buL noL enrolled wlLh
Lake-up raLes of 23.4 as publlshed by Lhe kalser lamlly loundaLlon for PealLh ollcy Analysls.
92

Group C are adulLs noL on Lhe chlldless adulL walver and wlLh lncomes up Lo 138 of lL. 1hls
estimate was derived by using data from the U.S. Census Bureaus American Community Survey for
2012, mulLlplled by a Lake-up raLe of 82 pursuanL Lo a sLudy for Lhe AsslsLanL SecreLary for lannlng
and LvaluaLlon, uSuPPS, by Lhe 8Anu CorporaLlon speclflcally on Lake-up raLes for Medlcald
enrollmenL per Lhe ACA.
93

Group D are Lhose persons who are currenLly covered by prlvaLe lnsurance buL would lose Lhelr
coverage due Lo Lhe anLlclpaLed effecL of employers dropplng coverage, employers Laklng oLher
acLlon encouraglng low-wage employees Lo slgn up for Medlcald as opposed Lo employer-provlded
lnsurance, or lnsurers cancelllng pollcles due Lo requlremenLs of Lhe ACA. LsLlmaLes of chlldren,
chlldless adulLs, and parenLs aL lncomes below 138 of lL, ln addlLlon Lo chlldren from 139 Lo
200 of lL, were derlved from CS daLa, whlch were furLher broken down lnLo subcaLegorles of
Lhose wlLh employer healLh lnsurance coverage and non-group coverage. 1he Lwo dlfferenL Lake-up
raLes applled were 93 for Lhose wlLh non-group coverage and 30.8 for Lhose wlLh employer-
based coverage. 1he assumpLlon of 93 comes from Lhe uSuPPS Cfflce of Lhe AcLuary.
94
1he ACA
was deslgned ln a manner Lo lncrease lnsurance cosLs for Lhls segmenL of Lhe populaLlon, whlch has
Lhe effecL of maklng many of Lhese pollcles lllegal, causlng Lhem Lo be wlLhdrawn by lnsurers. lL ls
llkely LhaL mosL of Lhe chlldless adulLs ln Lhls caLegory would have Lhelr pollcles wlLhdrawn and Lhe
replacemenL opLlons made avallable Lo Lhem wlll be slgnlflcanLly more expenslve. WlLh Lhe
expanslon of Medlcald, lL would become Lhe loglcal cholce Lo choose free coverage over non-group
pollcles LhaL wlll llkely be ouL of Lhelr prlce range. 8ecause Lake-up raLes never equal 100, Lhe
model assumed Lhe uSuPPS assumpLlon of 93 for Lhe mlddle value. 1he 8Anu CorporaLlon

92
John Holahan, Matthew Buettgens, Caitlin Carroll, and Stan Dorn, The Urban Institute, The Cost and Coverage Implications of
Lhe ACA Medlcald Lxpanslon: naLlonal and SLaLe-by-State Analysis, Sponsored and published by the kolset commlssloo oo
MeJlcolJ ooJ tbe uolosoteJ, november 2012
93
8en Sommers, 8lck kronlck, kenneLh llnegold, 8osa o, karyn SchwarLz, and Sherry Clled, Understanding Participation Rates in
Medicaid: Implications for the Affordable Care Act, A5l lssoe 8tlef, March 2012. Accessed aL:
hLLp://aspe.hhs.gov/healLh/reporLs/2012/Medlcald1akeup/lb.shLml.
94
ldem.
Append|x 8
compuLaLlon of 82 was used for Lhe low-end rlsk analysls. 98 was used Lhe hlgh-end rlsk analysls.
1he assumpLlon of 30.8 comes from a publlshed survey of Mcklnsey & Company.
93
1he proprleLary
research LhaL surveyed 1,329 employers ln lebruary 2011 assessed Lhelr aLLlLudes and plans on Lhe
ACA. Cne of Lhe many flndlngs was LhaL 24 of employers wlLh a low awareness of Lhe ACA LhoughL
Lhey mlghL llkely drop employee healLh coverage, 30.8 of employers wlLh medlum awareness
LhoughL Lhey llkely mlghL, and 34 of employers wlLh a hlgh level of awareness LhoughL Lhey mlghL
llkely drop. 1hese values are used ln Lhe rlsk analysls ln Sect|on VI of Lhls reporL.
lL ls lmporLanL Lo noLe LhaL employers can easlly deploy LacLlcs oLher Lhan dropplng healLh lnsurance
coverage alLogeLher Lo encourage Lhelr low-wage workers Lo slgn up for Medlcald. Lmployers wlLh
more Lhan flfLy employees are requlred under Lhe ACA Lo offer healLh lnsurance Lo lLs employees,
and federal law
96
requlres Lhem Lo have raLlonal pollcles LhaL do noL dlscrlmlnaLe, Lherefore
requlrlng Lhem Lo offer healLh care Lo all employees lf Lhey offer lL Lo some employees of Lhe same
full-Llme or parL-Llme sLaLus. Powever, by slmply requlrlng employees Lo make conLrlbuLlons Lo Lhe
cosL of Lhe premlum, lL can make Lhe employer-based healLh lnsurance prohlblLlvely expenslve Lo
low lncome employees, especlally when compared Lo Medlcald whlch has no premlum cosL share.
Actua|a| Cowt| Assumot|ons
1he model used sLandard acLuarlal meLhodologles Lo
forecasL populaLlon growLh facLors. SeparaLe growLh
facLors were generaLed accounLlng for poverLy by Lhe
followlng age groups: under 18, 18-64, over 63, and an
overall growLh facLor. ln addlLlon, growLh facLors were
calculaLed for Lhe LoLal populaLlon. 1he low-end and hlgh-
end values were calculaLed assumlng a 23 varlance.
1he resulLs of Lhe acLuarlal growLh facLors were compared Lo hlsLorlc MalneCare and poverLy growLh
beLween Lwo slmllar polnLs along Lhe buslness cycle for comparablllLy, and Lhey were found Lo be
slmllar. I|gure 100 shows Lhe flnal change ln populaLlon facLors used.

93
Mcklosey Ooottetly., already clLed.
96
See Self-Compllance 1ool for arL 7 of L8lSA: PlAA and CLher PealLh Care-Related Provisions, U.S. Department of Labor.
hLLp://www.dol.gov/ebsa/pdf/parL7-1.pdf, accessed uecember 19, 2013.
Age Category Low Lnd M|dd|e n|gh Lnd
under 18 2.31 3.08 3.83
18 Lo 64 1.86 2.48 3.10
63 and over 2.71 3.61 4.31
1oLal 2.09 2.78 3.48
opu|at|on Growth Iactors
"#$%&' (AA) *+:%41.#+3 >&+E.S "1-.+&6
Append|x 8
lMlMs
1he MMs were calculaLed for each caLegory, uslng daLa for
Sl? 2012-13, and was provlded by Lhe MuPPS 8eneflL
AnalyLlcs Leam. I|gure 101 shows Lhe acLual MMs per
caLegory.
opulaLlon groups wlLhouL calculaLed MMs were maLched
wlLh Lhe MMs of Lhe closesL populaLlon group LhaL had a
calculaLed MM. lor example, chlldless adulLs noL covered by
Lhe walver were assumed Lo have Lhe same MM as Lhose
covered by Lhe walver.
lMlM Cowt| lactos
ro[ecLlng Lhe growLh raLe for MMs ls complex because so many facLors come lnLo play. lnflaLlon
speclflc Lo Lhe healLh care lndusLry lnfluences Lhe rlse ln cosLs. 1he Consumer rlce lndex for medlcal
care for Lhe 8osLon-8rockLon-nashua, MA-nP-ML-C1 area, whlch lncludes Malne, was 3.9 over
Lhe lasL Len years. Powever, Medlcald relmbursemenL fees are negoLlaLed beLween CMS and Lhe
sLaLe and have been noLorlously low, Lhus creaLlng Lhe problem of noL havlng enough docLors wllllng
Lo serve Medlcald cllenLs. Lack of access can ln Lurn cause pollLlcal pressure Lo lncrease fees, buL
Lhese efforLs are consLralned by Lhe reallLy of llmlLed budgeLs. ConsequenLly, Medlcald fees lag
lnflaLlon. Powever, uLlllzaLlon ls also a cosL deLermlnanL, and some Medlcald paLlenLs Lend Lo use
servlces more frequenLly or ln more cosLly seLLlngs, such as emergency rooms. 1he model assumed
Lhe 2.9 facLor used by Lhe uSuPPS Cfflce of Lhe AcLuary, and ls slmllar Lo naLlonal hlsLorlc cosL.
1hls assumpLlon ls conservaLlve. 1he low-end and hlgh-end rlsk facLors assumed 1.9 and 3.9.

"#$%&' (A() U-.%14 *0*06 *'& I1.'$+&G
Category MM
1radlLlonal Medlcald 712.23
Aged 1,326.93
8llnd/ulsabled 1,333.38
Chlldren < 100 of lL 320.64
arenLs < 100 of lL 392.38
regnancy 912.29
SLaLe Cnly 1,783.96
CLher 1radlLlonal 234.13
CPl 222.04
Chlldless AdulLs (Walver) 314.18
arenLs Lo 138 of lL 271.46
losLer Chlldren 237.60
Append|x 8
lMAl
lMA raLes were provlded by Lhe MuPPS 8eneflLs AnalyLlc Leam. 8ecause Lhese are calculaLed
based on a federal formula whose facLors vary on an annual basls and because Lhey can change by
a whlm of Congress, lL ls dlfflculL Lo forecasL lMA raLes. lL was assumed LhaL lMA raLes wlll remaln
consLanL. 1he Lable ln I|gure 102 dlsplays Lhe assumed raLes.
8ecause Lhe lMA raLe for chlldless adulL under 100 of lL was unavallable aL Lhe Llme of wrlLlng
this report, the two potential FMAP rates for this category are listed as Childless Adult (<=100% of
lL)-1 and Childless Adult (<=100% of FPL)-2. These different reimbursement rates only impacts
sLaLe cosLs, noL LoLal cosLs. 8oLh raLes were consldered ln Lhe flnanclal model.
L|soooot|onate S|ae loso|ta| (LSl) A||otments
Maines disproportionate share hosplLal (uSP) alloLmenLs wlll be reduced over Llme uslng a
meLhodology based on sLaLe comparlsons ln unlnsured populaLlons and Lhe LargeLlng of paymenLs
Lo hosplLals wlLh a hlgh volume of Medlcald paLlenLs and hlgh volume of uncompensaLed care cosLs.
CMS has not yet released revised DSH allotments at the time of the writing of this report. Maines
alloLmenL was capped ln Sl? 2012-13 aL $86 mllllon, of whlch $30 mllllon ls used for Lhe chlldless
adulL walver and $36 mllllon for Lhe sLaLe psychlaLrlc hosplLals aL 8lvervlew and uoroLhea ulx. uSP
ls lncluded ln Lhe model as parL of Lhe overall budgeL cosL Lo operaLe MalneCare, whlch ls lncluded
ln boLh Lhe basellne and Lhe LesL scenarlos. 8ecause Lhe chlldless adulL walver ls explrlng, Lhe
assumpLlon was Lo keep Lhe value consLanL because no furLher lnformaLlon was avallable aL Lhe
Llme Lo assume oLherwlse. 1he lmpacL, however, would llkely be mlnor compared Lo Lhe oLher
poLenLlal cosLs and rlsks ldenLlfled by Lhe model. lf, for example, Malne conLlnues Lo recelve Lhe $30
mllllon, lL could choose Lo use lL for uncompensaLed care, whlch would requlre a maLch of $31.2
mllllon aL Lhe currenL lMA raLe. ln Lhe expanslon scenarlo, lL could be assumed LhaL Lhe $30 mllllon
would be phased ouL over a number of years, resulLlng ln a loss of $30 mllllon ln federal money buL
no sLaLe cosLs assoclaLed wlLh LhaL loss. lL could be argued, Lherefore, LhaL Lhere ls a poLenLlal sLaLe
cosL of $31.2 mllllon Lo Lhe sLaLe for noL expandlng, lf Lhe sLaLe were Lo recelve and accepL $30
"#$%&' (A8) U66%5'/ "0U* C1.'6
2013-14 2014-13 2013-16 2016-17 2017-18 2018-19 2019-20 2020-21 2021-22 2022-23 2023-24
Avallable lorecasL lorecasL lorecasL lorecasL lorecasL lorecasL lorecasL lorecasL lorecasL lorecasL
1radlLlonal Medlcald 61.81 61.33 61.33 61.33 61.33 61.33 61.33 61.33 61.33 61.33 61.33
CPl 73.27 73.09 90.34 96.09 96.09 96.09 96.09 96.09 96.09 96.09 96.09
losLer Chlldren 61.81 61.33 61.33 61.33 61.33 61.33 61.33 61.33 61.33 61.33 61.33
arenLs 61.81 61.33 61.33 61.33 61.33 61.33 61.33 61.33 61.33 61.33 61.33
Chlldless AdulL (<=100 lL)-1 80.78 82.70 86.34 88.31 89.36 91.90 91.30 90.00 90.00 90.00 90.00
Chlldless AdulL (<=100 lL)-2 80.78 100.00 100.00 97.30 94.30 93.30 91.30 90.00 90.00 90.00 90.00
Chlldless AdulL (101-138) 100.00 100.00 97.30 94.30 93.30 91.30 90.00 90.00 90.00 90.00
AdmlnlsLraLlon 61.36 61.36 61.36 61.36 61.36 61.36 61.36 61.36 61.36 61.36 61.36
AdmlnlsLraLlon (Lnhanced) 90.00 90.00 90.00 61.36 61.36 61.36 61.36 61.36 61.36 61.36
Append|x 8
mllllon from Lhe federal governmenL for uSP. Powever, Lhls would be a volunLary cosL and also a
pollLlcal declslon, whlch ls beyond Lhe scope of Lhls sLudy.
Aom|n|stat|ve Costs
1he model assumes admlnlsLraLlve cosLs pursuanL Lo an analysls and esLlmaLes by MuPPS. 8asellne
admlnlsLraLlve cosLs used hlsLorlc experlence, and afLer ad[usLlng for one-Llme federal funds and
oLher one-Llme paymenLs, lL esLlmaLed an annual growLh raLe of 2.46. lor Lhe LesL case, lL assumed
LhaL 97 addlLlonal personnel would be requlred Lo deLermlne ellglblllLy and manage Lhe addlLlonal
workload. 1hese cosLs were esLlmaLed Lo be $7.44 mllllon for Sl? 2014-13.

Append|x C: key AG Members Who Contr|buted to 1h|s keport

Aooeno|x C: ley AC 1eam Membes v|o Cont|buteo to 1||s 8eoot
Gary D. A|exander, I.D.
Mr. Alexander ls Lhe founder, presldenL, and CLC of Lhe Alexander Croup. Pe ls a naLlonally recognlzed
healLh-care and Medlcald experL, welfare reformer, and budgeL speclallsL. lor over 16 years, he has
Lransformed underperformlng sLaLe healLh and welfare agencles lnLo accounLable, value-orlenLed, and daLa
and performance-drlven sysLems by ploneerlng sLrucLural reforms and sLaLe-of-Lhe-arL Lechnology soluLlons
LhaL have lmproved ouLcomes and quallLy, lowered healLh-care cosLs, reduced fraud and wasLe, re-
englneered employmenL programs, modernlzed access, and ellmlnaLed budgeL deflclLs. A pragmaLlc and
declslve leader, Alexander has a Lrack record noL only of ldenLlfylng problems buL also assembllng Lhe rlghL
mlx of LalenL, pollcy makers, and sLakeholders Lo generaLe daLa-drlven soluLlons wlLh quanLlflable resulLs Lo
some of Lhe mosL vexlng challenges faclng federal, sLaLe, and local governmenLs.
rlor Lo foundlng Lhe Alexander Croup, Mr. Alexander served as ennsylvanla Governor Tom Corbetts
secretary of public welfare and Governor Tom Corbetts senior health and welfare advisor from 2011 to 2013.
ln LhaL dual role, he oversaw overall operaLlons, managemenL, and pollcy developmenL for one of Lhe largesL
healLh and welfare agencles ln Lhe naLlon, a deparLmenL wlLh a budgeL of $27.3 bllllon, 6 hosplLals, 3 sLaLe
lnLermedlaLe faclllLles, 94 offlces, 16,300 employees, and 2.2 mllllon publlc-asslsLance reclplenLs.
upon arrlval ln ennsylvanla, Mr. Alexander faced double-dlglL growLh, an uncoordlnaLed servlce sLrucLure,
and a fragmenLed organlzaLlon. 1o flx Lhese problems, he crafLed and lmplemenLed a cuLLlng-edge plan Lo
eradlcaLe fraud and wasLe called Lhe otetptlse-wlJe ltoqtom loteqtlty ooJ lmptovemeot loltlotlve. 1hls
program-lnLegrlLy lnlLlaLlve has been lauded by Medlcald and welfare-reform experLs and earned Lhe
deparLmenL a naLlonal lnnovaLlon award for Lxcellence and 8esL racLlce from Lhe Councll of SLaLe
CovernmenLs.
rlor Lo hls Lenure ln Lhe keysLone SLaLe, Mr. Alexander creaLed and lmplemenLed slmllar reforms as 8hode
Islands secretary of health and human services and human-servlces dlrecLor from 2006 Lo 2011. Pe ls Lhe
auLhor and archlLecL of Lhe 2009 landmark 8hode lsland Clobal Medlcald Walver LhaL, for Lhe flrsL Llme,
dellvered unprecedenLed flexlblllLy Lo a sLaLe Lo redeslgn lLs Medlcald program. 8ellevlng Lhe sLaLe of
burdensome federal mandaLes and requlremenLs, Lhls groundbreaklng reform lmproved care quallLy,
ouLcomes and access, lowered publlc cosLs, creaLed more cholces for reclplenLslncludlng more approprlaLe
care seLLlngsand properly aligned services and benefits. The waivers long-Lerm care redeslgn ls also belng
used as a model of reform around Lhe naLlon. ln lLs flrsL Lwo years, Lhe walver noL only saved approxlmaLely
$100 mllllon buL also kepL LoLal Medlcald spendlng aL bllllons of dollars below Lhe agreed-upon spendlng
llmlL. 1o Lhls day, Lhe walver conLlnues Lo help 8hode lsland solve budgeL deflclLs and lmprove quallLy. 8y
improving quality, choice and access for recipients and introducing accountability into Medicaid, Alexanders
lnlLlaLlve has been clLed as a model of enLlLlemenL reform, parLlcularly Medlcald and healLh care reform by
varlous experLs and publlcaLlons, lncludlng 1be woll 5tteet Iootool and Lhe ltovlJeoce Iootool.
Mr. Alexander has worked on boLh sldes of Lhe alsle and has a repuLaLlon for reachlng consensus Lo solve
complex problems. ConsequenLly, members of congress, elecLed offlclals, and pollcy makers conslsLenLly

seek hls advlce on enLlLlemenL reform. Pe holds a 8achelor of ArLs degree from norLheasLern unlverslLy and
a !urls uocLor (!.u.) from Suffolk unlverslLy School of Law.
Lr|k D. kando|ph
Mr. 8andolph spenL 28 years of hls professlonal career ln governmenL, lncludlng 21 years wlLh experlence ln
flscal analysls of leglslaLlon and governmenL programs LhaL lnvolved deLermlnlng flscal lmpacLs, forecasLlng
cosLs and revenues, budgeLlng, and worklng wlLh flnanclal and economlc models. Pe began hls career as a
program evaluaLor wlLh Lhe u.S. Ceneral AccounLlng Cfflce, whlch was renamed Lhe CovernmenL
AccounLablllLy Cfflce ln 2004. Pe Lhen worked flve years for Lwo dlfferenL sLaLes ln Lhe flelds of economlc
developmenL and sclence and Lechnology pollcy. AfLerwards, he achleved Lhe poslLlon of senlor analysL for
Chalrman uwlghL Lvans (u) of Lhe CommlLLee on ApproprlaLlons, ennsylvanla Pouse of 8epresenLaLlves. Pe
also spenL Lwo years as a speclal pollcy and flscal asslsLanL advlslng Mr. Alexander when he served as
SecreLary of ubllc Welfare for ennsylvanla Covernor 1om CorbeLL (8). Pe has LaughL prlnclples of
economlcs for 17 years. Pe has a MasLer of Sclence degree from 8ensselaer olyLechnlc lnsLlLuLe and Lwo
8achelor degrees from Lhe ennsylvanla SLaLe unlverslLy.
Murray M. 8||tzer
Mr. 8llLzer possesses over 30 years of experlence ln publlc admlnlsLraLlon and flnance wlLh a speclalLy ln
Medlcald and human servlces. Pe was Lhe Chlef llnanclal Cfflcer for Lhe 8hode lsland ueparLmenL of Puman
Servlces, overseelng a $1.3 bllllon budgeL and over 1,000 employees. Pe also served ln Lhe 8hode lsland
LeglslaLure as uepuLy Lo Lhe SenaLe llscal Cfflcer. ln Lhe SenaLe, as an advlsor Lo Lhe Ma[orlLy Leader, he
lmplemenLed a budgeL hearlng and revlew process LhaL allowed Lhe membershlp equal parLlclpaLlon ln
formulaLlng pollcy. Murray began hls career ln Lhe 8hode lsland SLaLe 8udgeL Cfflce where he deslgned and
implemented the structure for the states Consensus Medical Assistance and Caseload LsLlmaLlng
Conference, applylng professlonal forecasLlng Lools Lo over $2 bllllon ln healLh care and welfare spendlng.
1hroughouL hls publlc career Murray has successfully worked wlLh prlvaLe enLlLles Lo reduce Lhe cosL of
governmenL and dellver servlces LhaL have had a poslLlve lmpacL on Lhe llves of many consumers. Murray
holds a 8achelor of Sclence uegree ln 8esource 1echnology and Lconomlcs from Lhe unlverslLy of 8hode
lsland.
Ienn|fer M. W|er
Ms. Wler, C..A., has more Lhan 17 years of experlence. She has experLlse ln Medlcald and ls also exLremely
knowledgeable abouL lnformaLlon sysLems, sysLems modellng, and daLa mlnlng. Ms. Wler has spenL Lhe pasL
flve years dedlcaLed solely Lo Medlcald asslsLlng ln Lhe analysls of Lhe program from boLh quanLlLaLlve and
quallLaLlve perspecLlves. She has audlLed boLh flnanclal and pollcy componenLs and ls well versed ln federal
regulaLlons as Lhey perLaln Lo Lhe program. She has asslsLed ln Lhe drafLlng of leglslaLlon affecLlng several
componenLs of Lhe Arkansas Medlcald program, lncludlng Lhe creaLlon of Lhe Cfflce of Medlcald lnspecLor
Ceneral for Lhe SLaLe of Arkansas as well as leglslaLlon affecLlng provlder enrollmenL. lor Lhe pasL flve years
as a member of Lhe ulvlslon of Arkansas LeglslaLlve AudlL, she has been responslble for reporLlng on all
Medlcald and human servlce programs of lnLeresL Lo Lhe Ceneral Assembly and has acLed as an lndependenL

llalson beLween Lhe leglslaLors and Lhe program admlnlsLraLors. She has a 8achelor of Sclence ln AccounLlng
from Lhe unlverslLy of Arkansas aL LlLLle 8ock and ls a member of Lhe Arkansas SocleLy of rofesslonal
AccounLanLs and Lhe Arkansas lnformaLlon SysLem AudlL and ConLrol AssoclaLlon.
kev|n k. Gabr|e|
Mr. Cabrlel ls an acLuary and has 30 years of experlence and has worked ln Lhe healLhcare and employee
beneflLs areas for over 20 years. Pe began hls career wlLh a naLlonal wrlLer of group healLh lnsurance and
laLer moved Lo a palr of ma[or relnsurers ln Lhe PealLh arena. ln hls lasL poslLlon before becomlng a
consulLanL, kevln ran Lhe AccldenL and PealLh 8elnsurance dlvlslon for a ma[or A-rated life insurer. Kevins
worked has lncluded Lhe prlclng of a wlde range of medlcal producLs, Lhe evaluaLlon of managed care
neLworks and managed care lnLervenLlon programs, and Lhe assessmenL of llablllLles for lnsurers and
employers. More recenLly, he has worked on lssues relaLed Lo healLhcare reform and has been lnvolved ln
Lhe preparaLlon of blds for demonsLraLlon pro[ecLs relaLed Lo new healLhcare lnlLlaLlves. Mr. Cabrlel has a 8A
from Wesleyan unlverslLy ln MlddleLown, ConnecLlcuL, and an M8A from Lhe WharLon School of Lhe
unlverslLy of ennsylvanla. ln addlLlon, he ls a lellow of Lhe SocleLy of AcLuarles and a member of Lhe
Amerlcan Academy of AcLuarles.



8|b||ography

u|b||ogao|y
Alzenman n.C. and karen 1umulLy. uemocraLs Share Concerns Cver Medlcald Lxpanslon.
wosbloqtoo lost. !uly 13, 2012, p. A3.
Allen M.u., and Ceorge !. ArnaouLakls, M.u., !onaLhan 8. Crens, M.u., !ohn Mcuyer, M.u., !ohn
v. ConLe, M.u., Ashlsh S. Shah, M.u., ChrlsLlan A. Merlo, M.u., M..P. Insurance Status is
an lndependenL predlcLor of long-Lerm survlval afLer lung LransplanLaLlon ln Lhe unlLed
States. 1be Iootool of neott ooJ looq 1toosploototloo. volume 30, lssue 1. pp. 43 33,
!anuary 2011.
Amerlcan PosplLal AssoclaLlon. lacL SheeL on uncompensaLed Care. uecember 2010. Accessed aL:
hLLp://www.aha.org/conLenL/00-10/10medunderpaymenL.pdf.
American Psychological Association. LffecLs of overLy, Punger, and Pomelessness on Chlldren and
?ouLh. Accessed aL: hLLp://www.apa.org/pl/famllles/poverLy.aspx.
8aLklns, Sam. SLaLe by SLaLe lmpacL of ACA 8egulaLlons 2012. 1be Ametlcoo Actloo lotom. CcLober
2012. Accessed aL: hLLp://amerlcanacLlonforum.org/slLes/defaulL/flles/ACA_regs.pdf.
8towo, Covetoot of collfotolo, et ol. v. lloto et ol. 091233. May 23, 2011.
Cassldy, 8lll. Cassidy Eyes per CaplLa Caps for SLaLes as arL of Medlcald 8eform roposal. loslJe
neoltb lollcy. March 6, 2012. Accessed aL: hLLp://lnsldehealLhpollcy.com/lnslde-PealLh-
Ceneral/ubllc-ConLenL/cassldy-eyes-per-caplLa-caaps-for-sLaLes-as-parL-of-medlcald-
reform-proposal/menu-ld-869.hLml.
CenLers for ulsease ConLrol and revenLlon, PealLh-8elaLed CuallLy of Llfe (P8CCL). llgure 2: Mean
number of reporLed physlcally unhealLhy days ln Lhe pasL 30 days by sLaLe. Accessed aL:
hLLp://www.cdc.gov/hrqol/daLa/maps/flgure2-meanphyslcallyunhealLhy.hLm.
CenLers for Medlcare and Medlcald Servlces. Medlcald and CPl: CcLober MonLhly AppllcaLlons
and LllglblllLy ueLermlnaLlons. uecember 3, 2013. Accessed aL:
hLLp://www.medlcald.gov/AffordableCareAcL/Medlcald-Movlng-lorward-
2014/uownloads/Medlcald-CPl-MonLhly-LnrollmenL-8eporL.pdf
CenLer for Medlcare and Medlcald Servlces. MalneCare for Chlldless AdulLs SecLlon 1113
uemonsLraLlon. Accessed aL: hLLp://www.medlcald.gov/Medlcald-CPl-rogram-
lnformaLlon/8y-1oplcs/Walvers/1113/downloads/me/me-chlldless-adulLs-fs.pdf.
8|b||ography

Channel 4 kMCv.com. Audit reveals half of people enrolled in Ill. Medicaid program not eligible.
SL. Louls, 1elevlslon. Accessed aL: hLLp://www.kmov.com/news/[usL-posLed/AudlL-reveals-
half-of-people-enrolled-ln-lL-Medlcald-program-noL-ellglble-230386321.hLml.
Congresslonal 8udgeL Cfflce, MonLhly 8udgeL 8evlewSummary for llscal ?ear 2013. november
7 2013. hLLp://www.cbo.gov/publlcaLlon/44716.
Congresslonal 8udgeL Cfflce, CpLlons for 8educlng Lhe ueflclL: 2014 Lo 2023. november 2013.
EuroStat, Euro area and EU28 government debt up to 93.4% and 86.8 of Cu. oto5tot News
keleose. 133/2013. CcLober23, 2013.
lrallch !., eL. al., Clder AdulLs and AdulLs wlLh ulsablllLles: opulaLlon and Servlce use 1rends ln
Malne. cbottbook. 2012 LdlLlon. .1. unlverslLy of SouLhern Malne, Muskle School of ubllc
Servlce. Accessed aL: hLLp://muskle.usm.malne.edu/uA/AdulLs-ulsablllLles-Malne-Servlce-
use-1rends-charLbook-2012.pdf.
llemlng, C. uS PealLh Spendlng CrowLh ro[ecLed 1o Average 3.8 ercenL Annually 1hrough 2022.
neoltb Affolts 8loq oolloe. SepLember 18 2013. Accessed aL, hLLp://healLhaffalrs.org/blog/.
Conshorowskl, urew. Medlcald Lxpanslon Wlll 8ecome More CosLly Lo SLaLes. lssoe 8tlef No. J709.
30 AugusL 2012. Accessed aL: hLLp://Lhf_medla.s3.amazonaws.com/2012/pdf/lb3709.pdf.
Could, Lllse. Employer-Sponsored PealLh lnsurance Coverage ConLlnues Lo uecllne ln a new
uecade. ll 8tlefloq lopet #J5J. Lconomlc ollcy lnsLlLuLe. uecember 3 2012.
Gruber, Jonathan and Kosali Simon. Crowd-CuL 1en ?ears LaLer: Pave 8ecenL ubllc lnsurance
Expansions Crowded Out Private Health Insurance? Notloool 8oteoo cooomlc keseotcb,
!anuary 2007.
PealLhockeL. With Expansion Looming, Less than Half of Physicians Accept Medicaid. Accessed
aL: hLLp://www.healLhpockeL.com/healLhcare-research/lnfosLaL/less-Lhan-half-of-
physlclans-accepL-medlcald#.urhaxd-A1pC. uecember 10, 2013.
PealLh Affalrs, AugusL 2012 vol. 31. no. 8. pp. 1673-1679.
Holahan, John and Matthew Buettgens, Caitlin Carroll, and Stan Dorn. The Cost and Coverage
lmpllcaLlons of Lhe ACA Medlcald Lxpanslon: naLlonal and SLaLe-by-State Analysis. The
urban lnsLlLuLe, sponsored and publlshed by Lhe kolset commlssloo oo MeJlcolJ ooJ tbe
uolosoteJ, november 2012.
8|b||ography

korouklan h.u., Slran M., 8akakl M.u., M.S., ual M., 8aghavan M.u., h.u., uerek. Survlval
ulsparlLles by Medlcald SLaLus. coocet. volume 118. lssue 17. pp. 4271-3279. uecember
2011.
Laar, M.u., uamlen !. and CasLlgllano M. 8hamldlpaLl, u.C., Carlos M. Mery, M.u., M..P., Ceorge
!. SLukenborg, h.u., uavld 8. !ones, M.u., 8ruce u. Schlrmer, M.u., lrvlng L. kron, M.u., and
Corav Allawadl, M.u. rlmary ayer SLaLus AffecLs MorLallLy for Ma[or Surglcal CperaLlons.
Aoools of 5otqety. SepLember 2010, 232(3): pp. 344331.
MuPPS. 8alanclng lncenLlve aymenL rogram AppllcaLlon. May 2013. Accessed aL:
hLLp://www.medlcald.gov/Medlcald-CPl-rogram-lnformaLlon/8y-1oplcs/Long-1erm-
Servlces-and-SupporL/8alanclng/uownloads/Malne-8l.pdf.
MuPPS. MalneCare 8edeslgn 1ask lorce 8ecommendaLlon 8eporL. uecember 2012. Accessed aL:
hLLp://www.malne.gov/dhhs/malnecare-Lask-force/documenLs/2012-reporL.pdf.
MDHHS provided data on waiting lists. 1he MalneCare rogram 8lghL Slze, 8lghL Servlce, 8lghL
rlorlLles, Table comes from MDHHS presentation, Fall 2013, slide 19.
Muskle School CharLbook, Average Age of Malne Long 1erm Care users by SeLLlng Sl? 2010. llgure
3-1, p. 18.
naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers, 8oJqet ltocesses lo tbe 5totes. Summer 2008.
Accessed aL: hLLp://www.nasbo.org/slLes/defaulL/flles/8_2008.pdf.
naLlonal AssoclaLlon of SLaLe 8udgeL Cfflcers, 5tote xpeoJltote kepott. xomloloq llscol 2011
201J 5tote 5peoJloq, 2013. Accessed aL:
hLLp://www.nasbo.org/slLes/defaulL/flles/SLaLe20LxpendlLure208eporL2028llscal
202011-201320uaLa29.pdf.
naLlonal CenLer for LducaLlonal SLaLlsLlcs, ulqest of Jocotloool 5totlstlcs. 1able 174. Accessed aL:
hLLp://nces.ed.gov/programs/dlgesL/d12/Lables/dL12_174.asp.
National Conference of State Legislatures, A88A - Medlcald lMA lncrease rovlslons. Accessed
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uecember 2013. Accessed aL:
hLLp://www.usaLoday.com/sLory/news/naLlon/2013/12/08/healLhcaregov-medlcald-
ellglblllLy-quesLlons/3871113/.
8|b||ography

ark, Ldwln and MaLL Broaddus. Center for Budget and Policy Priorities. Medicaid Per Capita Cap
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8oy, Avlk. Pow uo 8lue SLaLes Lxpand Medlcald? 8y aylng uocLors. lotbes. Accessed uecember
1, 2013. Accessed aL: hLLp://www.forbes.com/slLes/LheapoLhecary/2012/07/23/how-do-
blue-sLaLes-expand-medlcald-by-paylng-docLors-less/.
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2011.
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8lndman, 1homas 8odenhelmer, M.u., M..P., 8rennan, Carolyn Clancy, M.u., Cllver leln,
Mu, lda Pellander, M.u., uavld u. PlmmelsLeln, M.u., Llnda 8. Murray, M.u., M..P., 1.
uonald 8ucker, h.u., 8on Sable, M.u., !effrey Scavorn, M.u., 8onald Shansky, M.u., Lllen
Shaffer, M..P., uavld Slobodkln, M.u., M..P., SLeve 1arzynskl, M.u., M..P., SLeffle
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A5l lssoe 8tlef. March 2012. Accessed aL:
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Medlclne ln SocleLy of Lhe new ?ork Academy of Medlclne May 20 and 21, 1991.
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8|b||ography

l.S.A., ChrlsLopher !. and !ohn u. klemm, h.u., A.S.A., M.A.A.A. ChrlsLlan !. Wolfe, A.S.A,
kaLhryn L. 8ennle and !esslca l. Shuff. 2012.
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CovernmenL. 1able 1.3. hLLp://www.whlLehouse.gov/omb/budgeL/hlsLorlcals.
upLon, lred and Senator Orrin Hatch, Making Medicald Work: roLecL Lhe vulnerable, Cffer
lndlvlduallzed Care, and Reduce Costs, May 1, 2013. Accessed aL:
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alysls/20130301Medlcald.pdf.
Urban Institute, Hard Question on Access to Healthcare Will we have enough Doctors?
hLLp://www.urban.org/lssues/hardquesLlons/accessLohealLhcare.cfm, uecember 10, 2013.
unlLed SLaLes AsslsLanL SecreLary for lannlng and LvaluaLlon (ASL) and unlLed SLaLes ueparLmenL
of PealLh and Puman Servlces lederal Medlcald AsslsLance ercenLages or lederal llnanclal
arLlclpaLlon ln SLaLe AsslsLance LxpendlLures lMA. CcLober 2013. Accessed aL:
hLLp://aspe.hhs.gov/healLh/fmap.hLm.
Washington Slgnlng up More eople for Medlcald Lhan rlvaLe lans. cotbollc Oolloe. uecember
6, 2013. Accessed aL: hLLps://www.caLhollc.org/healLh/sLory.php?ld=33430.


1he A|exander Group, LLC (AG) ls a governmenL and buslness consulLlng flrm LhaL dellvers cuLLlng-
edge daLa-drlven soluLlons, sLraLeglc buslness developmenL, and lnnovaLlve healLh-care and
Lechnology plaLformsLo lmprove efflclency, effecLlveness, and quallLy for our cllenLs. AC possesses
unlque experLlse ln Lhe governmenL healLh-care markeLplace, bullL upon Lwo decades of noL only
operaLlng large-scale healLh and human-servlces agencles buL also ploneerlng reforms LhaL saved
sLaLes bllllons of dollars and lmproved servlce quallLy. lounded ln 2013 by reformer Cary u.
Alexander, Lhe flrm ls Lhe only group of publlc offlclals who have deslgned, lmplemenLed, and
managed naLlonally acclalmed reforms llke Lhe kboJe lslooJ Clobol MeJlcolJ wolvet and, ln
ennsylvanla, 1be otetptlse-wlJe ltoqtom loteqtlty lloo and 1be neoltb ooJ nomoo 5etvlces
coooty 8lock Ctoot.
The firms specialties range from health care and social welfare to management consulting
lncludlng buL noL llmlLed Lo healLh care plan deslgn, Medlcald, Medlcare, long-Lerm care and
accredlLaLlon servlces Lo organlzaLlonal deslgn and resLrucLurlng, LransporLaLlon, LransacLlon
asslsLance, and leglslaLlve and flscal analysls. AC helps sLaLes and locallLles navlgaLe Lhe lnLersecLlon
of buslness and publlc pollcy whlle ldenLlfylng opporLunlLles LhaL enhance Lhe boLLom-llne and
advance Lhe healLh and well-belng of clLlzens. 8aLher Lhan remedlaLe complex and ouLdaLed healLh
care plans or asslsLance programs plecemeal, we help sLaLes and locallLles reform and resLrucLure
Lhelr enLlre healLh and human servlces sysLems. ueploylng cosL-effecLlve savlngs meLhodologles Lo
ensure a value-, LransparenL-, and efflclency-based sysLem, our reforms drlve lnnovaLlon, lmprove
servlce quallLy and performance, lncenLlvlze accounLablllLy and consumer engagemenL, modernlze
operaLlons, and rooL ouL fraud, wasLe, and abuse.
22 Whlsperlng lne 1errace
Creenvllle, 8l 02828
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