Social Security, Medicare and Medicaid Work for MiSSouri

www.StrengthenSocialSecurity.org

Our Social Security, Medicare and Medicaid Work for America series of 50 state reports includes much information that public officials, members of the press, and advocates will find useful. In addition to providing information about the programs’ history, character and vitality, as well as compelling, real-life stories, each report includes statistics about the number of people who receive benefits, the types of benefits they receive and the total amount of funds flowing from these programs into every state, its congressional districts and counties. Please note that a one-page fact sheet summarizing the data in this report can be found at the end of the report, directly following the endnotes. For congressional district-level Social Security data, please see “Appendix 1: Social Security Works for Missouri’s Congressional Districts,” toward the back of the report, just before the end notes. For county-level Social Security, Medicare, Medicaid and demographic data, please see “Appendix 2: Social Security, Medicare, and Medicaid Data for Missouri’s Counties,” toward the back of the report, just before the end notes.

ACKNOWLEDGMENTS

Like our Social Security, Medicare and Medicaid, this report is the product of the foresight and hard work of many people. Social Security Works partnered closely with the Alliance for Retired Americans who are coordinating the release of this report in Missouri. We are grateful to the following people for writing, designing and producing this report: Daniel Marans, Policy Director of Social Security Works (SSW), is the principal author and lead researcher, whose commitment to excellence, along with that of Alex Lawson, SSW’s Executive Director, drove the project to its successful conclusion. Michael Phelan, SSW’s Deputy Director managed the actual production of the report. We would like to thank Don Owens and Lacy Crawford, respectively, SSW’s Communications Director and Communications Associate for assembling, sometimes writing and editing the personal stories included in all 50 state reports. Dana Bell and Molly Checksfield, SSW’s Legislative and Policy Associates, played a crucial role in the reports’ completion, performing a significant amount of the initial research, drafting the appendices, and editing and verifying the data in the report. Tom Arnold-Forster, National Academy of Social Insurance Summer Policy Fellow, proofread the data. Very importantly, we want to acknowledge our appreciation to Barbara A. Woodruff and Fredricka (Fritzi) Lainoff for generously sharing their stories and views about the importance of Social Security in their lives. We would also like to acknowledge the staff of the Kaiser Family Foundation for their assistance in finding and understanding the Medicare and Medicaid data in the report, especially Research Associates Lindsay Donaldson and Jessica Stephens. Graphic design was provided by Deepika Mehta. This report also benefited from the work and commitment of several persons who assisted with a previous series of reports. Arloc Sherman, Senior Researcher, and Paul N. Van de Water, Senior Fellow, at the Center on Budget and Policy Priorities generously provided advice and access to poverty data analyzed by the Center. Alice Wade, Deputy Chief Actuary of the Social Security Administration, with the help of Virginia Reno, Vice President for Income Security at the National Academy of Social Insurance, graciously provided data on the value of Social Security’s survivors and disability insurance. The Center for Economic Policy and Research provided the invaluable analysis and graph showing the causes of the recent run-up in federal deficits. The data presented in this report speaks volumes about the importance of Social Security to families, communities and state and local economies. We hope the report is useful to you as you work to strengthen Social Security in this 77th anniversary year. Please contact the Social Security Works Communications Director, Don Owens, if you have questions about this report: dowens@socialsecurity-works.org. Nancy Altman and Eric Kingson Founding Co-directors, Social Security Works Co-chairs, Strengthen Social Security Coalition The Alliance for Retired Americans is a grassroots organization representing more than 4 million retirees and seniors nationwide. Headquartered in Washington, DC, the Alliance’s mission is to advance public policy that protects the health and economic security of older Americans by teaching seniors how to make a difference through activism. Learn more about The Alliance and its work at www.retiredamericans.org The mission of Social Security Works is to protect and improve the economic status of all Americas, especially disadvantaged and at-risk populations, and, in so doing, to promote social justice for current and future generations of children as well as young, middle-aged and older adults. www.socialsecurity-works.org The Strengthen Social Security Coalition is made up of more than 320 national organizations and many state organizations, representing more than 50 million Americans. The Coalition is united around core principles, which include that Social Security benefits should not be cut and, instead, should be increased for those who are most disadvantaged, and the belief that our nation’s Social Security, Medicare and Medicaid systems are fundamental to the well-being of America’s families and to the type of nation we are. www.strengthensocialsecurity.org
Social Security, Medicare and Medicaid Work for MiSSouri

introduction and SuMMary
“We can never insure one-hundred percent of the population against one-hundred percent of the hazards and vicissitudes of life. But we have tried to frame a law which will give some measure of protection to the average citizen and to his family against the loss of a job and against poverty-ridden old age. This law, too, represents a cornerstone in a structure which is being built but is by no means complete. It is a structure intended to lessen the force of possible future depressions. It will act as a protection to future Administrations against the necessity of going deeply into debt to furnish relief to the needy. The law will flatten out the peaks and valleys of deflation and of inflation. It is, in short, a law that will take care of human needs and at the same time provide for the United States an economic structure of vastly greater soundness.” —Franklin D. Roosevelt, August 14, 1935

In 1935, when President Franklin D. Roosevelt signed the Social Security Act into law he called it a cornerstone, the foundation of a structure to be maintained and built upon by and for future generations. Social Security could not protect all Americans against every risk, but, as the President said, it could lessen the consequences of lost earnings in old age for workers and their families. Since then, we have built our Social Security structure carefully and deliberately. In 1939, we added Survivors Insurance benefits for widows and dependent children, eventually extending it to widowers as well. Disability Insurance benefits were added in 1956, followed by Medicare and Medicaid in 1965. The automatic cost-of-living adjustment (COLA) was added in 1972, designed to maintain the purchasing power of benefits no matter how long someone lives. We built, maintained and strengthened these institutions for a reason: to enable working men and women to

protect themselves and their families. We built them because we, as a nation, value hard work, personal responsibility, and human dignity; we care for our parents, our children, our spouses, our neighbors and ourselves. This report reveals the success of these institutions for Missouri and the nation. The numbers tell part of the story: how many people receive benefits in Missouri, in its congressional districts and its counties; how many dollars flow into these jurisdictions in a year; the types of benefits and the types of people who receive benefits. Perhaps more importantly, the report presents the stories of hardworking Missourians and their families whose lives are immeasurably better because of the protections they have earned. As you read through this report, think of the people you know. Family members who live in dignity in old age because they can count on a monthly Social
FIGURE 11

Social Security, Medicare and Medicaid’s impact on the economy and Population of Missouri
PROGRAM BENEFICIARIES IN MISSOURI PERCENT OF RESIDENTS RECEIVING BENEFITS AVERAGE BENEFIT TOTAL ANNUAL BENEFITS2

Social Security Medicare Medicaid

1,166,223 975,145 1,065,266

19.5 percent 16.3 percent 17.8 percent

$12,854 $9,826 $7,273

$15 billion $10 billion $7.7 billion

Sources: Social Security Administration, 2011; U.S. Census Bureau; Kaiser Family Foundation, 2011; Economic Policy Institute, 2011.

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Security check that they or another family member have earned. Think of that older person who has Medicare, and with it the peace of mind that he or she can receive medical care without becoming bankrupt. Think of a family you know who is able to care for a functionally disabled child at home because Medicaid is there. Think of a grandparent, a parent, an older aunt, uncle, cousin or family friend, whose life savings may have been lost paying for nursing home care, but who is still able to receive that care because of Medicaid. Think, too, of how these institutions, like the nation’s highway system, are part of a rich legacy by those who came before, a legacy that keeps working in good times and bad. Throughout the past few difficult years, Social Security, Medicare, and Medicaid have been even more vital than before for Missouri residents, and the lifeblood of many small businesses, hospitals and nursing homes and home caregivers. Virtually all of the jobs our Social Security, Medicare, and Medicaid systems support stay in America. As important as these programs’ protections are today, the need for Social Security, Medicare and Medicaid programs will only increase in coming years. The population of persons aged 65 and over is growing. Income growth is slow for most of

today’s workers. Jobs are less secure, and many workers have sustained substantial losses of home equity and other savings. Furthermore, employers, who historically have offered supplements to Social Security, are increasingly terminating traditional pension plans and either not replacing them, or replacing them with far more risky and inadequate 401(k) savings accounts. Cutting these programs would threaten our families’ economic security and health and deepen our jobs crisis. Indeed, the nation should be thinking about expanding, not cutting, these programs and the protections they provide. They, like our highways, are so fundamental to our family and community life, and, in an increasingly uncertain environment, ever more important to middle-aged and young workers and those who will follow. We are much wealthier as a nation than we were in 1935, 1939, 1956, 1965, or 1972, when these structures were begun and improved. Now it is our turn to maintain and build upon that structure, as those who came before have done. It is our turn to preserve and improve these valuable systems for ourselves and for those who follow. It is our turn to build a legacy for our nation’s children and grandchildren so when they become workers, they will have the economic security that Social Security, Medicare, and Medicaid provide.

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Social Security WorkS
We built our Social Security system because it is the most efficient, secure, universal and fair way for Americans to replace wages in the event of death, disability, or old age. For over 75 years, even as our nation has endured wars, political crises and severe economic recessions, Social Security has never missed a payment; it has paid every dollar of earned benefits, on time and in full. In the wake of the greatest financial crisis since the Great Depression, the risks of investing money on Wall Street or in real estate have never been clearer. Since 2008, millions of Americans have seen their savings wiped out, as the value of 401(k)s and home equity have plummeted. Meanwhile, Social Security continues to prove reliable. That is why our Social Security system is now more important than ever. In a world of risky investment schemes and unpredictable markets, Social Security is a fortress of security and reliability. In this uncertain world, where no one is invulnerable to the tragedy of premature death or serious and permanent disability, Social Security is there to cushion the economic blow of such tragedies. Today, 56 million Americans receive benefits each month—retired and disabled workers, their families, and surviving family members.3 Its benefits to Missouri residents, and all Americans, are very modest, but vital; the average national benefit was $12,982 a year in 2010.4 These benefits are the building block of retirement income security for middle class Americans. In 2010 two out of three households aged 65 and over relied on Social Security for half or more of their income, and over 1 out of 3 relied on Social Security for 90 percent or more of their income.5 The program lifted 20 million Americans out of poverty in 2008, including one million children.6 Social Security can pay all benefits in full and on time for the next twenty years. After that, if Congress were not to act, it could still pay more than 75 cents
Social Security, Medicare and Medicaid Work for MiSSouri

on every dollar of earned benefits.7 The shortfall is equivalent to 1 percent of Gross Domestic Product (GDP), which is roughly the amount of revenues that would be lost to the federal budget from extending the George W. Bush-era tax cuts benefitting the richest 2 percent of American households—those with taxable income above $250,000 a year.8 All we need to maintain our Social Security system is a simple adjustment: have everyone, including millionaires and billionaires, pay the same rate as ordinary Americans. While the vast majority of Americans must make payroll tax contributions on all of their wages, millionaires and billionaires only do so on the first $110,100 of their earnings this year. Asking all Americans to pay the same rate would come very close to closing Social Security’s entire projected 75-year funding gap. While the federal budget has run a deficit in every year but five over the last half century, Social Security is not allowed to pay benefits unless it has the funds to cover every penny of the cost, and is not allowed to borrow any shortfall.9 That means that Social Security does not, and, by law, cannot add a penny to the federal deficit or debt (which is simply the accumulation of annual deficits).10 Maintaining our Social Security system has nothing to do with reducing the federal budget deficit, and therefore should be off the table in deficit talks. It should not be part of any deficit reduction legislation considered by our nation’s leaders.

Social Security Works for Missouri’s Residents and Economy
• Social Security provided benefits to 1,166,223 people in 2010, 1 out of 5 residents (19.5 percent).11 • Missouri residents received Social Security benefits totaling $15 billion in 2010, an amount equivalent to 6.2 percent of the state’s annual GDP (the total value of all goods and services produced).12
3

FIGURE 2

FIGURE 3

Poverty rate for Beneficiaries 65 and older With and Without Social Security, 2006–2008
47.5% 50%

Missouri’s Social Security Beneficiaries, 2010

17% Disabled Workers 8% Widow(er)s 62% Retired Workers 4% Spouses 8% Children

6.8%
65+

8.7% PA
Women 65+

n Poverty rate without Social Security n Poverty rate with Social Security
Source: Center on Budget & Policy Priorities Source: Social Security Administration, 2012

• The average Social Security benefit in 2010 was $12,854.13 • Social Security lifted 487,000 Missouri residents out of poverty in 2008.14

Social Security Works for Missouri’s Women
• Social Security provided benefits to 595,950 Missouri women in 2010, 1 out of 5 women (19.5 percent).21 • Social Security provided benefits to 44,808 spouses in 2010, 1 out of 25 (3.8 percent) of all beneficiaries.22 [Figure 3] • Social Security lifted out of poverty 180,000 Missouri women aged 65 and older in 2008.23 • Without Social Security, the poverty rate of elderly women would have increased from 1 out of 11 (8.7 percent) to 1 out of 2 (50 percent).24 [Figure 2]

Social Security Works for Missouri’s Seniors15
• Social Security provided benefits to 725,690 retired workers in 2010, two-thirds (62.2 percent) of beneficiaries.16 [Figure 3] • The typical benefit received by a retired worker in Missouri was $13,819 in 2010.17 • Social Security provided benefits to 94,195 widow(er)s in 2010, 1 out of 12 (8.1 percent) of all beneficiaries.18 [Figure 3] • Social Security lifted out of poverty 314,000 Missouri residents aged 65 and older in 2008.19 • Without Social Security, the elderly poverty rate in Missouri would have increased from 1 out of 15 (6.8 percent) to nearly half (47.5 percent).20 [Figure 2]

Social Security Works for Missouri’s Workers with Disabilities25
• Social Security provided disability benefits for 202,465 workers in 2010, 1 out of 6 (17.4 percent) of all beneficiaries.26 [Figure 3] • The typical benefit received by a disabled worker beneficiary in Missouri was $11,390 in 2010.27

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Social Security Works for Missouri’s Children28
• Social Security is the major life and disability insurance protection for more than 95 percent of Missouri’s 1,425,436 children.29 • Social Security provided benefits to 99,065 children in 2010,30 and it is the most important source of income for the 125,635 children living in Missouri’s grandfamilies, which are households headed by a grandparent or other relative.31

BARBARA A. WOODRuff
My retirement funds were spent during the years in which I could not work due to being the sole caregiver of my mother. My savings quickly disappeared keeping her afloat. The only extravagance we indulged were movie rentals, but with Mom so ill, I felt it necessary for her to have some sort of entertainment. And joy it was watching comedies with her and seeing her laugh and forget, if even for a moment, the pain which racked her body. After her passing, I found myself homeless, jobless and with very little money. Fortunately I was able to live with an Aunt until I got on my feet and even then it was difficult. The job market was not good even then for an aging management professional so I took whatever I could. What followed were many years of near minimum wage employment—whatever it took to keep food on my table and a roof over my head. Early retirement came when I was laid off in ’09 and could not find new employment at my age. In May of 2011 my unemployment ran out completely, leaving me with no income at all. I had always thought I’d work until the day I passed. After all, I liked working and would have been happy doing so until the end. Turning 62 in June of that year, my only choice was to retire early. From June of that year to my first Social Security check in late August, I sold most everything I could to pay the rent, feed the utility monster and put gas in my car. Then I sold the car to pay an outlandish electric bill after a particularly hard winter. I find myself living on less than $700 a month. Even with Social Security, it’s difficult at times to make ends meet. While not eligible for Medicare for another two years, I’m fortunate to have Medicaid since I have had two heart attacks in my ‘retirement’. If not for Social Security and Medicaid, I’m not sure that I’d be alive today.

Social Security Works for Missouri’s African Americans
• In Missouri, Social Security provided benefits to 107,776 African Americans in 2009, 1 out of 7 (15.2 percent) of all African American residents.32 • Nationwide, Social Security provided nearly three-quarters (73.7 percent) of the income of African American elderly couples and unmarried individuals receiving benefits, on average, in 2010. Social Security was 90 percent of the total income for half (49.4 percent) of these African American elderly households.33 • Nationwide, 3 out of 10 (32.1 percent) of all African American beneficiaries received disability benefits in 2009; for white beneficiaries it was about half of that number (15.9 percent).34

Social Security Works for Missouri’s Latinos
• In Missouri, Social Security provided benefits to 1 out of 7 (13.6 percent) Latino households in 2010, 7,602 households.35 • Nationwide, Social Security provided more than three-quarters (77 percent) of the total income of Latino elderly couples and unmarried individuals receiving benefits, on average, in 2010. Social Security was 90 percent of the income for more than half (55.1 percent) of these Latino elderly households.36 • The Social Security Administration estimates that Latinos receive a higher rate of return on their Social Security contributions than the overall population—the highest of any group. That’s because they tend to have lower lifetime income, longer life expectancies, higher incidence of disability and larger families.37
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Social Security Works for Missouri’s American Indians and Alaska Natives
• In Missouri, Social Security provided benefits to 3 out of 10 (30.3 percent) American Indian and Alaska Native households in 2010, 9,213 households.38 • Nationwide, Social Security provided 90 percent of the income for 15 percent of elderly American Indian and Alaska Native married couples, and 57 percent of elderly unmarried persons in 2010.39 • Since Social Security has a higher income replacement rate for workers with lower earnings, Social Security replaces more of American Indians’ and Alaska Natives’ pre-retirement earnings than the overall population. The median earnings of working‐age American Indians and Alaska Natives are about $34,000, compared to $41,500 for all working-age people. Social Security provides average benefits of about $13,206 and $11,265 annually for American Indian and Alaska Native men and women aged 65 and older, respectively.40

Social Security Works for Missouri’s Rural Communities44
• Social Security is more important to rural Missourians than to other Missourians. Nearly 1 out of 4 (23.7 percent) rural Missourians received Social Security compared with 1 out of 6 (17.9 percent) non-rural Missourians in 2010.45 • Social Security is more important to the local economies of Missouri’s rural counties than to its non-rural counties. Total personal income in Missouri’s 81 rural counties was $47.8 billion in 2010 of which $4.5 billion, or 9.4 percent, was from Social Security. By comparison, total personal income in the state’s 34 non-rural counties was $172.8 billion, of which $10.5 billion, or 6.1 percent, was from Social Security.46

Social Security Works for Missouri’s Working families
• Through their hard work and payroll tax contributions, nearly all Missouri workers earn Social Security’s retirement, disability and survivorship protections for themselves and their families. • Social Security is the most valuable disability and life insurance protection for most Missouri workers. Nationwide, an estimated 3 out of 10 working‐aged men and 1 out of 4 working‐aged

Social Security Works for Missouri’s Asian Americans
• In Missouri, Social Security provided benefits to 1 out of 9 (10.6 percent) Asian American households in 2010, 3,861 households.41 • Nationwide, Social Security provided two‐thirds (68.9 percent) of the total income for Asian American households with beneficiaries aged 65 and older, on average, in 2010. Social Security was 90 percent of the income for 4 out of 10 (41.7 percent) of these Asian American elderly households.42 • Nationwide, Asian Americans and Pacific Islanders receive a high rate of return from Social Security because of their long life expectancies. An Asian American or Pacific Islander man aged 65 in 2010, can expect to live until age 85, compared to age 82 for all men. An Asian American or Pacific Islander woman of the same age can expect to live until age 88, compared to age 85 for all women.43

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women will become severely disabled before reaching retirement age. An estimated 1 out of 11 working‐aged men and 1 out of 20 working‐aged women will die before reaching retirement age.47 • A 30-year-old worker who earns about $30,000 and who has a spouse and two young children, receives Social Security insurance protection equivalent to private disability and life insurance policies worth $465,000 and $476,000, respectively.48 Social Security is a commitment made to all Americans that has withstood the test of time. It represents the best of American values—rewarding hard work, honoring our parents, caring for our neighbors, and taking responsibility for ourselves and our families. Social Security is based on a promise that if you pay in, then you earn the right to guaranteed benefits.

fREDRICKA (fRITzI) LAINOff 82 years old St. Louis, MO
In June 2008 I developed pneumonia, was hospitalized, and had several more medicines added to the list I already take. By mid-September I fell into the “donut hole”. There was absolutely no extra cash in our budget to pick up the costs for all my prescriptions. I was faced with a dilemma. What other prescriptions could I cut in half in order to be able to afford to at least take some of each? Every month, our utilities must be paid each month. We have to keep food on the table. To do more is not in the budget. We have had to cut back on many other activities, and joining friends to “eat out” has been out of the budget for several years. We thought we’d be comfortable in retirement, able to travel a bit, and “live the good life” with our pension and social security and the investments on the sale of our home. Cancer can cut through a lot of savings and wreck havoc with a mortgage. Both of us are cancer survivors. When we retired we sold the house and what little was left from the sale after we paid our bills has been used up to make those proverbial ends meet. Medical costs first took our savings and now eat up almost all our pension. We find ourselves in a difficult financial position deciding, do we buy medicines, or lower the heat below the 68 we have it during the winter and not use the a/c in the summer? Where else do we cut costs? Without our social security we would be destitute. And, I worry about our son and what the future holds for him and his family if cuts are made to social security.

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Medicare WorkS
We built our Medicare system because it is by far the best way to provide America’s seniors and people with disabilities with affordable health care they can count on. For nearly half a century, Medicare has given seniors and people with disabilities access to critical health care. It protects beneficiaries and their families against health-related expenditures that might otherwise overwhelm their finances—or worse, force them to forego medical treatment needed to survive. Private health insurance companies, which must generate returns for their shareholders, were not— and are not—willing or able to insure seniors and people with disabilities at affordable rates. That is because seniors and people with disabilities have greater medical needs and thus are more costly than the young and healthy. Prior to Medicare, only about half of seniors had health insurance. Those who were insured paid nearly three times as much as younger people, even though they had, on average, only half as much income.49 Without Medicare, many people would not be able to afford basic medical services. Medicare beneficiaries are mainly people of modest means. Half had incomes below $22,000 a year in 2010.50 Already more than one-quarter of many beneficiaries’ Social Security benefit is eaten up by out-of-pocket health care costs.51 Medicare works—for seniors and people with disabilities, as well as people with end-stage renal disease (ESRD) and Amyotrophic Lateral Sclerosis (ALS, or Lou Gehrig’s disease). The program provides significant hospital, physician, medical testing, pharmaceutical, rehabilitation, medical equipment and other important services to seniors, people with disabilities and people with ESRD and ALS.52 Medicare provided health care coverage to 48.7 million Americans in 2011, of whom over 8 out of 10 (40.4 million) were aged 65 or older; and 1 out of 6 (8.3 million) were severely disabled workers.53 The average benefit per Medicare beneficiary in 2011 was $12,042.54 Medicare consists of four parts, each of which provides different medical benefits. Medicare Part A, the Hospital Insurance (HI) program, covers in-patient hospital as well as select kinds of skilled nursing facility services, home health and hospice care. HI is earned during one’s working years, and paid for by insurance contributions of 2.9 percent of wages, divided equally between employers and employees.55* Medicare Part B, the Supplemental Medical Insurance (SMI) program, helps pay for physician and preventive care services. SMI is a voluntary program, funded by premiums, generally deducted

* Starting in 2013, the Affordable Care Act levies an “additional 0.9 percentage point Hospital Insurance tax on earned income for households with incomes exceeding $200,000 for singles and $250,000 for married couples filing jointly. In addition, it would add a 3.8 percent Unearned Income Medicare Contribution for such high-income households to unearned income including interest, dividends, annuities, royalties and rents (excluding income from active participation in S corporations).” White House, “Title IX. Revenue Provisions,” Health Reform Details, 2012. http://www.whitehouse.gov/health-care-meeting/proposal/titleix/ targeted-healthcare-tax

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from beneficiaries’ Social Security checks, and from general revenue.56 (Medicaid covers the premium and out-of-pocket costs for those low-income beneficiaries who are enrolled in Medicaid.) Medicare Part C, also known as the Medicare Advantage program, allows beneficiaries to enroll in a private insurance plan, in lieu of Medicare Parts A and B. These private plans receive payments from Medicare to cover physician and hospital service, and in most cases, prescription drug benefits. Medicare Advantage Plans cost more for the same services as provided under Parts A and B.57 According to the White House, “Medicare pays Medicare Advantage insurance companies over $1,000 more per person on average than traditional Medicare.”58 These extra costs result not only in higher government outlays but also higher Part B premiums for those enrolled in traditional Medicare. The Patient Protection and Affordable Care Act (ACA) of 2010 includes provisions which seek to make the costs of Part C closer to those of Part A and Part B.59 About 11.5 million Medicare beneficiaries were enrolled in Medicare Advantage as of April 2010— one-quarter (24.5 percent) of all beneficiaries.60

Medicare Part D, the prescription drug benefit, covers most outpatient prescription drugs. Part D benefits are provided by private plans that contract with Medicare and are purchased voluntarily by Medicare beneficiaries. They exist independently, or as part of a Medicare Advantage plan. Part D is funded by beneficiary premiums, generally deducted from beneficiaries’ Social Security checks, and from general revenue. In addition, states are required to pay premiums for low-income beneficiaries who are enrolled in Part D programs. 27.6 million beneficiaries were enrolled in a Part D plan in 2010—4 out of 10 (41.7 percent) of all beneficiaries.61* As health care costs skyrocket, our Medicare system is more critical than ever. Medicare does a better job of controlling health care costs than private health insurance plans. While Medicare’s costs per person increased by about 4.7 percent a year from 1999 to 2009, the costs of similar benefits under private insurance rose 6.9 percent—nearly 50 percent more.62 [Figure 4] Medicare’s superior cost-control record is no coincidence; it is a function of Medicare’s concentrated purchasing power. As Professor Jacob Hacker of Yale University notes, Medicare is “capable of using its concentrated purchasing power to pioneer new payment methods that bring down costs.” Hacker cites Medicare’s implementation of a “prospective payment system” and a “resource-based physician fee schedule” in 1983, and “volume controls” on Medicare physician spending in the 1990s, as examples of Medicare’s success in pioneering payment methods that reduced underlying health care costs.63 Even though the traditional Medicare program, Parts A and B, covers people who, on average, have more health care claims and more expensive medical conditions than private insurance, its administrative costs are lower than those of private health insurance plans. Medicare’s administrative costs

FIGURE 4

average annual increase in Spending on common Benefits,* 1999–2009
6.9%

4.7%

Medicare

Private Health Insurance *As of January 1, 2011, the Affordable Care Act ensures that seniors who reach the prescription drug coverage gap, known commonly as the “donut hole,” will receive discounts on brand-name and generic prescription drugs covered by Medicare Part D that increase gradually until the coverage gap is completely closed in 2020. Medicare.gov, “Closing the Coverage Gap— Medicare Prescription Drugs Are Becoming More Affordable,” January 2012. http://www.medicare.gov/publications/pubs/pdf/11493.pdf 9

*Common benefits refers to benefits commonly covered by Medicare and private health insurance.
Source: Center for Medicare & Medicaid Services, 2010

Social Security, Medicare and Medicaid Work for MiSSouri

were less than 2 percent of its total expenditures in 2011.64 Private health insurance’s administrative costs, which include additional costs such as advertising, retained profit to insurers and taxes paid by insurers, are generally much higher. The Congressional Budget Office (CBO) estimated that in 2007 these administrative costs varied from about 7 percent for large employer plans with 1,000 or more covered employees to as much as 30 percent for insurance sponsored by very small firms or purchased by individuals.65 CBO estimated that while Medicare paid about $150 per person enrolled, large employer plans paid about $300 per person enrolled, and small employers and individuals paid roughly $1,000 per person enrolled, on average.66 The traditional Medicare Program, Parts A & B, is also administered more efficiently than Medicare Advantage, Part C, which is provided by private insurers who contract with Medicare. An analysis by CBO shows that administrative costs accounted for less than 2 percent of expenditures in the traditional Medicare program, compared to 11 percent in the Medicare Advantage program in 2005.67 Maintaining our Medicare system is simple. As health care costs increase system-wide, Medicare’s costs rise as well. It is primarily as a result of system-wide cost increases, that Medicare has significant longterm funding challenges. The solution is to slow the growth of health care costs for everyone, as other developed countries have done—not to cut Medicare’s benefits. Cutting Medicare’s benefits simply shifts costs to the sickest and oldest among us, forcing some seniors and people with disabilities to forego treatment, living shorter, less healthy—and more medically costly—lives as a result.

Medicare Works for Missouri Residents
• Medicare insured 975,145 Missourians in 2009— 1 out of 6 (16.3 percent) state residents.70

Medicare Works for Missouri’s Seniors
• 794,032 of Missouri’s 975,145 Medicare beneficiaries were aged 65 or older in 2009— 8 out of 10 (81.4 percent) beneficiaries.71

Medicare Works for Missouri’s People with Disabilities
• 182,382 of Missouri’s 975,145 Medicare beneficiaries were people with disabilities in 2009—1 out of 5 (18.7 percent) beneficiaries.72

Medicare Works for Missouri’s Residents with End-Stage-Renal Disease (ESRD).
• End-stage-renal disease (ESRD) occurs when a person’s kidneys stop functioning at a level needed for everyday life. People suffering from ESRD generally must undergo dialysis treatment or receive a kidney transplant, which are both prohibitively expensive.73

Medicare Works for Missouri’s Residents with Amyotrophic Lateral Sclerosis (ALS).
• Amyotrophic Lateral Sclerosis, more commonly known as ALS, or Lou Gehrig’s disease, is a nervous system disease that gradually shuts down all muscles in a person’s body, eventually resulting in death from respiratory failure.74 Many Missouri residents with ALS would impoverish themselves or their families without the help of Medicare. Seniors and people with disabilities cannot be economically secure if they are one illness away from bankruptcy. Medicare should be strengthened, not cut. As private sector health insurance continues to rise in cost, Medicare is more important than ever.

Medicare Works for Missouri’s Economy
• Medicare provided $10 billion in benefits in 2009—23 percent of all health care spending in the state.68 The average expenditure per Medicare beneficiary was $9,826.69

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10

Medicaid WorkS
We built our Medicaid system to provide health care for low-income families, children, seniors and people with disabilities. For nearly half a century, Medicaid has provided critical health coverage for low-income Americans. While Medicaid originally only insured Americans receiving cash welfare assistance, Congress expanded it over the years to help insure those left behind by the private insurance system.* It is a lifeline for those who have nowhere else to go.75 Medicaid insured 62.6 million Americans in 2009.76 Like Medicare, it is an important source of funding for rural hospitals and inner-city health care facilities. Medicaid is essential because private health insurance is unaffordable for millions of Americans. Private health insurance costs have risen dramatically in recent years. Average annual premiums for a family with employer-sponsored health insurance rose to $15,073 in 2011—a 9 percent increase from the previous year.77 Medicaid is especially crucial to people in need of community- and institutionally-based long-term care services. Medicare does not cover most long-term care costs, and private insurance plans that cover long-term care are often prohibitively expensive. As a result, many individuals exhaust their assets under the weight of steep long-term care costs, and have nowhere to turn but Medicaid. In short order, longterm care patients and their families can go from the middle class to a life of poverty in which they need assistance. Two-thirds of all Medicaid spending is for seniors and people with disabilities.78 One out of every four seniors and people with disabilities depended on Medicaid in 2010—16 million people. That includes 15.4 percent of all seniors (6.3 million) and 44.6 percent of people with disabilities (9.8 million).79 Medicaid is also crucially important to children, who are about half of its beneficiaries nationwide.80 More than one in four of the nation’s children receive their health insurance through Medicaid.81 Maintaining our Medicaid system, like our Medicare system, is simple. As health care costs increase system-wide, Medicaid’s costs rise as well. It is primarily as a result of system-wide cost increases that Medicaid has significant long-term funding challenges. The solution is to slow the growth of health care costs for everyone, as other developed countries have done—not to cut Medicaid’s benefits. Cuts in federal funding to Medicaid will shift costs to states, if they have the funds to pick up the shortfall, or worse, to individuals and families who can least

*The Affordable Care Act’s expansion of Medicaid and Children’s Health Insurance Program (CHIP) eligibility alone is projected to result in the enrollment of an additional 32 million Americans in Medicaid and CHIP by 2022. Congressional Budget Office, “Table 3. March 2012 Estimate of the Effects of the Affordable Care Act on Health Insurance Coverage,” Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act, March 2012. http://www.cbo.gov/sites/default/files/ cbofiles/attachments/03-13-Coverage%20Estimates.pdf Social Security, Medicare and Medicaid Work for MiSSouri 11

afford it. More troubling still, it may make life-saving medical care inaccessible for those who need it.

Medicaid Works for Missouri’s Economy
• Medicaid provided $7.7 billion in benefits in 2009—18.6 percent of all health care spending in the state.82 The average expenditure per Medicaid beneficiary was $7,273.83

Medicaid Works for Missouri Residents
• Medicaid insured 1,065,266 Missourians in 2009—1 out of 6 (17.8 percent) state residents.84

Medicaid Works for Missouri’s Children
• Medicaid insured 582,361 children in 2009—4 out of 10 (40.9 percent) children in the state.85

o $44 million to mental health facilities (2.3 percent) o $153 million to intermediate care facilities for the intellectually disabled (8 percent).88 o Medicaid insured the vast majority of Missouri residents who opt for nursing home care. 23,000 of Missouri’s 37,810 nursing home residents were Medicaid beneficiaries in 2010—2 out of 3 (60.8 percent) residents.89 The average annual cost of nursing home care for a semi–private room in Missouri was $51,100 in 2010.90 Given the high cost of nursing home care, many Missouri residents would not be able to afford it without Medicaid.

Medicaid Works for Missouri’s Seniors
• 94,318 of Missouri’s 1,065,266 Medicaid beneficiaries were aged 65 or older in 2009—1 out of 11 (8.9 percent) beneficiaries.86

Medicaid Works for Missouri During Economic Recessions
Because Medicaid eligibility is contingent upon having low income, the program expands to accommodate those who have lost jobs or earnings during a recession. Nationwide, between June 2008 and June 2009, the height of the Great Recession, monthly Medicaid enrollment rose by 3.3 million. That amounts to a 79 percent increase from the average annual enrollment rate between 2000 and 2007. While there are several factors that fuel Medicaid enrollment, experts believe that job losses and resulting losses of employer-based insurance and declining income, cause more people to qualify for Medicaid.91 As financially strapped states cut Medicaid, the last thing the nation’s seniors, people with disabilities, and low-income children need is for the federal government to cut the program at the national level. Like Social Security and Medicare, this vital program should be strengthened, not cut.

Medicaid Works for Missouri’s People with Disabilities
o 203,645 of Missouri’s 1,065,266 Medicaid beneficiaries were people with disabilities in 2009—1 out of 5 (19.1 percent) beneficiaries.87

Medicaid Works for Missouri’s Long-Term Care Residents.
• Medicaid provided $1.9 billion in long-term care benefits for Missouri residents in 2009. That includes: o $865 million in home health care services (45.5 percent) o $838 million to nursing home facilities (44.1 percent)

Social Security, Medicare and Medicaid Work for MiSSouri

12

concluSion
The large run-up in federal deficits in recent years resulted primarily from huge tax cuts in 2001 and 2003; the unpaid costs of the Iraq and Afghanistan wars; the Great Recession, which dramatically reduced tax collections and increased unemployment compensation and other spending; the economic stimulus and recovery spending; and the Wall Street bank bailout.92 [Figure 5] By law, Social Security can only pay benefits if it has the income to cover its costs. Its income is primarily the result of insurance contributions paid by hardworking Americans and their employers. It does not have borrowing authority which is why it never has and never will contribute to federal budget deficits. Likewise, large anticipated yearly increases in health care expenditures, public and private, reflect longterm structural problems in the nation’s health care
FIGURE 5

system. Compared to other industrial democracies, the United States expends roughly twice as much per person on health care generally without providing coverage for all our citizens. While the nation’s recent health care reform is expected to bend the cost curve and to expand coverage, health care expenditures are still expected to rise for many years, well in excess of inflation. That’s bad for consumers, employers and the economy, but it is not the fault of Medicare and Medicaid. In fact, Medicare is the most efficient part of the health care system, averaging just 2 percent in administrative costs compared to about 7 percent for large group plans and as much as 30 percent for plans purchased by individuals.93 To reduce the federal debt, Congress should be looking at its causes. It should not cut Social Security, Medicare, and Medicaid, which were built to protect working persons and their families against lost wages and the high cost of health care, and which are so vital to the economic security of our nation. Social Security, Medicare and Medicaid represent the best of America’s values, including caring for aging parents and neighbors, reward for hard work, personal responsibility and dignity. In Missouri, these programs spend about $32.3 billion a year, providing benefits to an average of 1 out of 6 residents for each program.94 It is no surprise that poll after poll shows that Americans overwhelmingly support these programs and do not want to see them cut. Cutting them would weaken the economic security of all Americans. While that would be bad policy anytime, it would be disastrous in this time of widespread economic loss. The old, the disabled and today’s workers have a stake in preserving these foundational systems— for themselves, their families, their children and grandchildren. And politicians have the opportunity to maintain and improve these paramount achievements for future generations, just as previous Congresses and presidents have done for us.
13

causes of recent run-up in federal deficits
1600 1400 1200 1000
Billions of dollars

ACTUAL DEFICITS

800 600 400 200 0 -200 -400 2001 DEFICITS WITHOUT THESE FACTORS 2003 2005 2007 2009 2011

n Wars in Iraq and Afghanistan n Bush-era tax cuts n Recocvery measures n TARP, Fannie and Freddie n Economic downturn
Source: Center for Economic and Policy Research, 2012

Social Security, Medicare and Medicaid Work for MiSSouri

appendix 1: Social Security Works for Missouri’s congressional districts
State total total annual benefits ($ in millions)* number of residents in state/ congressional district number of residents receiving Social Security benefits Percent of residents receiving Social Security benefits Women SOCIAL SECURITY BENEFICIARIES BY CATEGORY Retired workers Disabled workers CongreSSional DiStriCtS 1 2 3 4 5 6 7 8 9

$14,801M $1,382M $1,788M $1,526M $1,805M $1,443M $1,619M $1,832M $1,745M

$1,661M

5,988,927

587,069

706,622

625,251

679,375

633,887

693,974

721,754

656,894

684,101

1,166,223

108,896

120,471

113,930

148,321

110,354

125,159

151,663

154,448

132,981

19.5%

18.5%

17.0%

18.2%

21.8%

17.4%

18.0%

21.0%

23.5%

19.4%

595,950

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

725,690

63,874

85,543

71,369

92,828

69,264

81,712

93,664

84,763

82,673

202,465

21,797

12,518

20,130

25,492

20,263

18,541

27,040

33,628

23,056

Widow(er)s

94,195

8,253

9,628

9,419

11,625

8,030

10,456

12,253

13,943

10,588

Spouses

44,808

2,818

5,477

4,069

5,954

3,180

5,005

6,353

6,804

5,148

Children

99,065

12,154

7,305

8,943

12,422

9,617

9,445

12,353

15,310

11,516

Sources: US Census Bureau, Profile of General Population and Housing Characteristics: 2010, 2011. SSA, “Missouri,” Congressional Statistics, December 2010, 2011. SSA, “Table 5.J5.1: Number by state or other area and sex, December 2010.” Annual Statistical Supplement, 2011, February 2012. *The annual benefits for the Congressional districts were calculated by taking the monthly benefits and multiplying by 12. The state annual benefits number is the sum of the congressional district numbers and is not necessarily consistent with state totals cited elsewhere in the report.

Social Security, Medicare and Medicaid Work for MiSSouri

14

appendix 2: Social Security, Medicare, and Medicaid data by county, in Missouri’s counties (Page 1/4)
MISSOURI COUnty DeMOgRaphICS, 2010 SOCIal SeCURIty BenefItS, 2010 SOCIal SeCURIty BenefICIaRIeS By ChaRaCteRIStIC, 2010* MeDICaRe

Social Security, Medicare and Medicaid Work for MiSSouri

County

RuralMedian Urban population Continuum household Code (2003) Income % in poverty Children population over age 65 annual total Benefits total Beneficiaries Retired Workers Disabled Widow(er)s Spouses Workers

% of population Over age 65

% of population Receiving Benefits

% Receiving Medicare, 2010

15

total Counties Adair Andrew Atchison Audrain Barry Barton Bates Benton Bollinger Boone Buchanan Butler Caldwell Callaway Camden Cape Girardeau Carroll Carter County Cass County Cedar County Chariton Christian Clark Clay Clinton Cole Cooper Crawford Dade Dallas Daviess DeKalb Dent Douglas Dunklin

5,988,927 25,607 17,291 5,685 25,529 35,597 12,402 17,049 19,056 12,363 162,642 89,201 42,794 9,424 44,332 44,002 75,674 9,295 6,265 99,478 13,982 7,831 77,422 7,139 221,939 20,743 75,990 17,601 24,696 7,883 16,777 8,433 12,892 15,657 13,684 31,953

115 7 3 9 6 6 6 1 9 9 3 3 7 1 3 7 5 6 9 1 6 9 2 9 1 1 3 6 6 8 2 8 3 7 6 7

44,306 32,015 53,150 43,587 40,899 34,838 36,851 39,265 30,920 36,972 42,202 41,210 32,919 39,216 47,098 42,955 44,569 39,071 28,524 57,368 31,542 39,800 48,041 36,809 55,835 51,846 52,835 41,925 34,555 33,452 37,589 38,279 41,804 34,327 29,830 29,372

15.3% 22.2% 10.1% 11.6% 18.4% 18.9% 17.6% 15.7% 20.6% 19.5% 18.8% 15.9% 19.3% 13.9% 13.8% 14.6% 15.2% 15.7% 24.5% 8.5% 20.1% 14.0% 11.1% 16.3% 9.5% 11.1% 11.2% 16.7% 19.3% 21.7% 19.5% 17.2% 16.5% 19.1% 23.3% 27.3%

838,294 3,210 2,681 1,227 4,084 6,271 2,132 3,019 4,936 2,059 15,072 12,501 7,265 1,576 5,460 9,534 10,834 1,779 1,040 13,490 3,126 1,675 9,464 1,261 24,964 3,260 9,325 2,702 4,017 1,617 2,853 1,441 1,771 2,977 2,716 5,268

14.0% 12.5% 15.5% 21.6% 16.0% 17.6% 17.2% 17.7% 25.9% 16.7% 9.3% 14.0% 17.0% 16.7% 12.3% 21.7% 14.3% 19.1% 16.6% 13.6% 22.4% 21.4% 12.2% 17.7% 11.2% 15.7% 12.3% 15.4% 16.3% 20.5% 17.0% 17.1% 13.7% 19.0% 19.8% 16.5%

19.5% 17.8% 18.6% 26.2% 21.3% 24.4% 25.0% 24.9% 35.1% 25.3% 13.4% 19.3% 26.6% 20.6% 18.9% 26.6% 19.2% 25.6% 29.1% 17.9% 29.1% 25.0% 18.4% 24.9% 15.9% 18.5% 18.3% 20.8% 24.6% 27.1% 25.4% 22.8% 16.8% 26.7% 26.3% 26.4%

$14,998,245,000 $53,030,000 $40,809,000 $18,495,000 $69,287,000 $101,633,000 $35,446,000 $51,072,000 $84,378,000 $35,130,000 $284,711,000 $218,075,000 $124,347,000 $23,785,000 $105,305,000 $157,896,000 $183,493,000 $28,490,000 $19,833,000 $240,559,000 $47,728,000 $23,067,000 $178,640,000 $21,243,000 $492,682,000 $50,451,000 $178,142,000 $45,101,000 $72,594,000 $25,049,000 $49,052,000 $23,067,000 $26,838,000 $48,067,000 $39,314,000 $91,905,000

1,166,223 4,570 3,215 1,490 5,425 8,695 3,100 4,240 6,695 3,125 21,870 17,200 11,365 1,945 8,365 11,690 14,540 2,380 1,825 17,825 4,075 1,955 14,265 1,775 35,225 3,840 13,910 3,665 6,085 2,140 4,255 1,920 2,165 4,180 3,595 8,440

725,690 202,465 2,805 825 2,135 425 975 170 3,340 925 5,355 1,615 1,840 505 2,550 750 4,335 1,280 1,735 685 13,560 4,010 10,650 2,960 5,885 2,690 1,240 305 5,010 1,720 8,415 1,550 9,130 2,385 1,415 370 885 475 11,865 2,550 2,555 695 1,260 255 9,045 2,335 1,080 310 23,170 5,425 2,465 570 8,765 2,140 2,320 645 3,410 1,290 1,355 355 2,430 895 1,290 265 1,405 300 2,375 855 2,205 640 4,240 2,135

94,195 380 295 185 545 645 290 405 455 255 1,440 1,590 1,090 170 605 715 1,260 275 165 1,355 315 215 1,065 165 2,660 330 920 280 525 170 395 145 210 370 275 835

44,808 160 155 85 240 360 170 215 255 150 645 640 445 95 225 405 645 130 85 705 190 105 580 85 1,205 165 345 120 245 110 185 105 110 180 175 340

99,065 400 205 75 375 725 295 320 370 300 2,215 1,360 1,255 135 805 605 1,120 190 215 1,350 320 120 1,240 135 2,765 310 1,740 300 615 150 350 115 140 400 300 890

16.6% 14.8% 12.7% 23.1% 17.8% 21.7% 18.6% 19.5% 30.5% 18.3% 11.7% 17.5% 21.9% 20.2% 14.8% 19.4% 16.8% 23.0% 24.6% 13.3% 25.7% 20.8% 14.7% 19.6% 13.8% 17.9% 15.5% 17.4% 16.7% 22.9% 18.5% 17.5% 11.3% 22.3% 18.9% 22.3%

*State totals do not equal the sum of county figures, because individual county figures provided by SSA are rounded.

appendix 2: Social Security, Medicare, and Medicaid data by county, in Missouri’s counties (Page 2/4)
MISSOURI COUnty DeMOgRaphICS, 2010 SOCIal SeCURIty BenefItS, 2010 SOCIal SeCURIty BenefICIaRIeS By ChaRaCteRIStIC, 2010* MeDICaRe

Social Security, Medicare and Medicaid Work for MiSSouri

County

RuralMedian Urban population Continuum household Code (2003) Income % in poverty Children population over age 65 annual total Benefits total Beneficiaries Retired Workers Disabled Widow(er)s Spouses Workers

% of population Over age 65

% of population Receiving Benefits

% Receiving Medicare, 2010

16

Franklin Gasconade Gentry Greene Grundy Harrison Henry Hickory Holt Howard Howell Iron Jackson Jasper Jefferson Johnson Knox Laclede Lafayette Lawrence Lewis Lincoln Linn Livingston McDonald Macon Madison Maries Marion Mercer Miller Mississippi Moniteau Monroe Montgomery Morgan

101,492 15,222 6,738 275,174 10,261 8,957 22,272 9,627 4,912 10,144 40,400 10,630 674,158 117,404 218,733 52,595 4,131 35,571 33,381 38,634 10,211 52,566 12,761 15,195 23,083 15,566 12,226 9,176 28,781 3,785 24,748 14,358 15,607 8,840 12,236 20,565

1 6 8 2 7 7 6 8 8 3 7 6 1 3 1 4 9 6 1 6 9 1 7 6 2 7 7 8 5 9 6 7 3 9 8 8

47,530 39,688 35,755 38,059 35,017 34,324 37,016 27,957 39,141 39,383 33,211 33,059 44,620 37,565 52,841 43,327 33,076 35,688 45,621 38,800 36,501 50,307 35,323 39,821 33,352 37,130 33,841 38,877 39,975 35,184 34,266 30,252 44,475 36,950 38,145 34,374

14.1% 12.7% 14.5% 19.1% 17.5% 17.1% 17.2% 22.6% 14.2% 15.5% 21.3% 21.0% 16.8% 17.6% 12.1% 17.8% 21.0% 18.2% 11.9% 16.7% 16.4% 11.2% 15.9% 16.7% 19.7% 15.1% 19.1% 15.2% 16.4% 14.8% 21.3% 27.5% 14.4% 15.3% 16.8% 20.6%

14,000 3,062 1,381 38,593 2,100 1,854 4,345 2,846 1,043 1,609 6,909 1,899 83,990 15,714 24,394 5,644 828 5,556 5,495 6,300 1,664 5,715 2,430 2,766 2,887 3,026 2,167 1,646 4,507 763 3,897 2,188 2,153 1,648 2,286 4,535

13.8% 20.1% 20.5% 14.0% 20.5% 20.7% 19.5% 29.6% 21.2% 15.9% 17.1% 17.9% 12.5% 13.4% 11.2% 10.7% 20.0% 15.6% 16.5% 16.3% 16.3% 10.9% 19.0% 18.2% 12.5% 19.4% 17.7% 17.9% 15.7% 20.2% 15.7% 15.2% 13.8% 18.6% 18.7% 22.1%

20.5% 26.6% 28.6% 19.3% 24.1% 25.5% 28.6% 36.9% 25.7% 20.8% 27.3% 27.4% 17.4% 20.3% 18.0% 14.5% 26.3% 24.3% 22.4% 23.6% 21.9% 17.5% 25.0% 23.1% 18.4% 26.0% 28.1% 21.2% 22.4% 24.4% 21.6% 23.5% 19.5% 25.2% 24.5% 30.4%

$274,911,000 $50,780,000 $21,365,000 $665,803,000 $28,527,000 $25,256,000 $77,982,000 $42,900,000 $15,284,000 $25,195,000 $122,328,000 $34,254,000 $1,566,815,000 $285,988,000 $529,272,000 $95,820,000 $11,758,000 $97,900,000 $95,418,000 $104,661,000 $26,204,000 $120,978,000 $36,370,000 $41,926,000 $47,740,000 $47,861,000 $40,091,000 $22,873,000 $76,607,000 $10,421,000 $61,614,000 $38,535,000 $36,516,000 $27,105,000 $37,477,000 $78,504,000

20,765 4,050 1,930 53,070 2,475 2,285 6,360 3,550 1,260 2,105 11,020 2,910 117,350 23,795 39,275 7,645 1,085 8,660 7,465 9,105 2,235 9,195 3,185 3,510 4,255 4,050 3,440 1,945 6,450 925 5,340 3,370 3,040 2,230 3,000 6,255

12,865 2,710 1,135 32,530 1,615 1,505 3,875 2,370 760 1,375 6,175 1,455 74,070 13,755 22,620 4,840 680 5,000 4,885 5,535 1,375 5,250 2,045 2,240 2,405 2,595 1,930 1,210 3,760 610 3,245 1,750 1,935 1,435 1,790 4,235

3,665 630 295 9,650 325 300 1,190 555 155 340 2,340 735 21,200 4,720 8,155 1,275 145 1,690 1,140 1,585 330 1,945 500 540 920 600 725 385 1,205 125 970 760 500 325 560 1,055

1,645 290 165 4,485 265 225 535 285 170 155 950 265 8,385 2,145 3,150 570 110 760 600 725 220 685 290 320 320 345 320 145 550 85 400 385 235 200 280 385

785 165 90 2,295 125 120 280 155 85 75 500 150 3,395 965 1,575 335 70 430 260 405 100 385 125 150 175 210 160 65 220 50 185 125 100 100 135 200

1,805 255 245 4,105 145 135 480 185 85 160 1,055 305 10,300 2,210 3,770 625 80 775 580 855 210 935 230 260 435 300 305 140 720 55 540 345 270 170 230 380

17.8% 24.1% 24.9% 17.0% 22.4% 23.2% 25.4% 27.0% 22.4% 17.0% 23.5% 24.1% 15.4% 19.7% 13.4% 11.9% 22.2% 20.7% 19.4% 17.4% 20.0% 13.3% 23.9% 20.4% 14.8% 21.9% 22.4% 15.7% 20.9% 19.6% 20.6% 19.5% 15.3% 22.4% 22.5% 25.1%

*State totals do not equal the sum of county figures, because individual county figures provided by SSA are rounded.

appendix 2: Social Security, Medicare, and Medicaid data by county, in Missouri’s counties (Page 3/4)
MISSOURI COUnty DeMOgRaphICS, 2010 SOCIal SeCURIty BenefItS, 2010 SOCIal SeCURIty BenefICIaRIeS By ChaRaCteRIStIC, 2010* MeDICaRe

Social Security, Medicare and Medicaid Work for MiSSouri

County

RuralMedian Urban population Continuum household Code (2003) Income % in poverty Children population over age 65 annual total Benefits total Beneficiaries Retired Workers Disabled Widow(er)s Spouses Workers

% of population Over age 65

% of population Receiving Benefits

% Receiving Medicare, 2010

17

New Madrid Newton Nodaway Oregon Osage Ozark Pemiscot Perry Pettis Phelps Pike Platte Polk Pulaski Putnam Ralls Randolph Ray Reynolds Ripley St. Charles St. Clair St. Genevieve St. Francois St. Louis Saline Schuyler Scotland Scott Shannon Shelby Stoddard Stone Sullivan Taney Texas

18,956 58,114 23,370 10,881 13,878 9,723 18,296 18,971 42,201 45,156 18,516 89,322 31,137 52,274 4,979 10,167 25,414 23,494 6,696 14,100 360,485 9,805 18,145 65,359 998,954 23,370 4,431 4,843 39,191 8,441 6,373 29,968 32,202 6,714 51,675 26,008

7 3 6 9 3 9 7 7 4 5 6 1 2 5 9 9 6 1 9 9 1 8 6 4 1 6 9 9 5 9 9 7 8 9 6 9

32,921 40,955 39,823 27,646 49,058 28,709 28,152 43,200 36,882 39,765 37,169 67,791 34,837 48,374 32,643 43,763 37,537 50,278 29,819 29,213 65,281 30,998 48,031 35,630 55,290 37,537 31,978 36,272 37,457 26,600 37,829 35,994 37,788 33,932 34,281 32,076

24.5% 15.5% 17.0% 25.0% 10.8% 24.5% 31.3% 13.6% 17.9% 18.0% 17.8% 7.3% 21.0% 15.1% 19.5% 11.0% 17.7% 11.1% 24.0% 26.6% 6.1% 21.2% 11.2% 18.9% 10.5% 21.0% 20.7% 16.6% 18.5% 25.6% 14.9% 18.2% 16.3% 17.6% 20.0% 23.8%

3,045 8,857 3,077 2,153 2,077 2,279 2,693 2,960 6,203 6,157 2,883 9,967 5,025 3,768 1,076 1,676 3,605 3,483 1,343 2,646 40,378 2,295 2,911 9,354 149,493 3,699 870 879 5,872 1,462 1,239 5,346 7,870 1,144 9,150 4,682

16.1% 15.2% 13.2% 19.8% 15.0% 23.4% 14.7% 15.6% 14.7% 13.6% 15.6% 11.2% 16.1% 7.2% 21.6% 16.5% 14.2% 14.8% 20.1% 18.8% 11.2% 23.4% 16.0% 14.3% 15.0% 15.8% 19.6% 18.1% 15.0% 17.3% 19.4% 17.8% 24.4% 17.0% 17.7% 18.0%

23.4% 21.2% 15.9% 27.2% 19.0% 32.8% 25.3% 20.5% 20.8% 19.8% 21.0% 14.8% 21.6% 11.7% 26.5% 22.9% 19.9% 20.7% 29.6% 28.9% 15.3% 29.9% 22.2% 23.1% 18.8% 21.6% 24.0% 21.8% 24.8% 27.1% 24.8% 27.0% 29.9% 24.6% 24.5% 23.5%

$49,941,000 $147,013,000 $45,198,000 $31,495,000 $31,992,000 $37,161,000 $48,530,000 $47,691,000 $102,910,000 $102,910,000 $47,849,000 $192,514,000 $77,799,000 $65,202,000 $14,895,000 $28,843,000 $59,364,000 $63,657,000 $23,323,000 $43,666,000 $802,201,000 $35,142,000 $52,056,000 $183,565,000 $2,713,138,000 $61,018,000 $11,722,000 $11,807,000 $112,734,000 $24,016,000 $18,288,000 $92,366,000 $123,398,000 $17,729,000 $157,044,000 $67,147,000

4,435 12,325 3,720 2,965 2,630 3,190 4,620 3,895 8,760 8,940 3,890 13,225 6,720 6,110 1,320 2,325 5,060 4,860 1,980 4,080 54,995 2,935 4,025 15,070 187,330 5,050 1,065 1,055 9,700 2,290 1,580 8,100 9,615 1,650 12,635 6,115

2,125 7,500 2,505 1,620 1,730 2,000 2,130 2,455 5,325 5,165 2,395 9,080 4,010 3,285 830 1,490 2,795 3,020 1,105 2,120 37,570 1,735 2,460 7,955 127,975 3,055 670 655 5,155 1,230 1,005 4,530 6,875 1,050 8,395 3,685

1,070 2,140 425 640 400 595 1,230 605 1,635 1,750 645 1,745 1,190 1,250 205 380 1,110 805 400 955 7,090 580 715 3,505 23,585 910 155 145 2,170 515 215 1,780 1,280 270 2,100 1,150

505 1,040 395 260 200 220 485 345 740 740 385 910 630 600 140 175 445 405 185 370 4,220 270 325 1,410 15,120 400 110 115 935 205 170 730 570 140 845 485

220 565 200 165 110 155 155 160 335 380 170 465 315 280 70 120 215 245 105 180 2,015 140 190 600 7,420 160 60 65 405 95 95 370 365 65 470 270

515 1,080 200 280 190 220 620 330 725 910 295 1,025 575 690 75 160 495 385 185 455 4,100 210 340 1,600 13,230 525 70 80 1,035 245 95 690 525 125 825 525

18.4% 12.7% 14.8% 22.8% 15.0% 26.3% 20.0% 17.2% 18.8% 17.7% 17.8% 11.7% 20.1% 10.1% 23.8% 13.8% 19.1% 14.7% 22.0% 23.0% 12.9% 23.9% 17.2% 19.7% 16.9% 18.2% 26.0% 17.9% 21.7% 18.4% 23.3% 22.6% 23.5% 20.1% 20.5% 20.1%

*State totals do not equal the sum of county figures, because individual county figures provided by SSA are rounded.

appendix 2: Social Security, Medicare, and Medicaid data by county, in Missouri’s counties (Page 4/4)
MISSOURI COUnty DeMOgRaphICS, 2010 SOCIal SeCURIty BenefItS, 2010 SOCIal SeCURIty BenefICIaRIeS By ChaRaCteRIStIC, 2010* MeDICaRe

County
34,985 49,157 32,823 28,626 42,966 34,246 29,608 32,767 19.0% 12.7% 24.0% 23.4% 17.2% 15.8% 23.9% 27.7% 3,476 4,749 3,378 2,895 4,752 514 3,291 35,175 16.4% 14.6% 13.4% 21.4% 13.1% 23.7% 17.5% 11.0% 22.6% 20.4% 22.0% 30.4% 21.3% 26.9% 28.2% 16.8% $55,704,000 $90,335,000 $63,865,000 $45,770,000 $91,334,000 $6,384,000 $57,115,000 $630,661,000 4,780 6,620 5,540 4,110 7,710 585 5,300 53,685 2,845 4,295 2,620 2,195 4,470 400 2,945 29,175 935 1,070 1,485 1,015 1,505 60 1,070 13,145 360 485 455 345 660 55 495 4,075 160 260 290 200 370 40 280 1,015 480 510 690 350 705 30 510 6,275

RuralMedian Urban population Continuum household Code (2003) Income % in poverty Children population over age 65 annual total Benefits total Beneficiaries Retired Workers Disabled Widow(er)s Spouses Workers

% of population Over age 65

% of population Receiving Benefits

% Receiving Medicare, 2010
20.0% 15.7% 17.0% 29.5% 19.4% 24.5% 24.7% 14.4%

Social Security, Medicare and Medicaid Work for MiSSouri

Vernon Warren Washington Wayne Webster Worth Wright St. Louis City

21,159 32,513 25,195 13,521 36,202 2,171 18,815 319,294

7 1 1 9 2 9 6 1

*State totals do not equal the sum of county figures, because individual county figures provided by SSA are rounded. Population: US Census Bureau, “Profile of General Population and Housing Characteristics: 2010,” 2010 Demographic Profile Data, 2010. http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml rural-Urban Continuum Codes: United States Department of Agriculture, Economic Research Service (ERS), “Measuring Rurality: Rural-Urban Continuum Codes,” 2003. http://www.ers.usda.gov/data-products/ rural-urban-continuum-codes ERS designates counties as rural or urban based on population density, grading them on a scale of 1 to 9, with 1 being the most urban and 9 being the most rural. Counties are considered rural if they are designated 4 or higher. Median Household income: US Census Bureau, Table 1: 2010 Poverty and Median Income Estimates - Counties, November 2011. http://www.census.gov/did/www/saipe/data/statecounty/data/2010.html Percentage of Households in Poverty: US Census Bureau, Table 1: 2010 Poverty and Median Income Estimates - Counties, November 2011. http://www.census.gov/did/www/saipe/data/statecounty/data/2010.html Population aged 65 or older: US Census Bureau, “Age Groups and Sex: 2010,” 2010 Census Summary File 1, 2011. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=DEC_10_ SF1_QTP1&prodType=table total annual Social Security Benefits: Bureau of Economic Analysis (BEA), Regional Economic Accounts: Local Area Personal Income, “Old-age, Survivors and Disability Insurance (OASDI) benefits,” CA 35 Personal current transfer receipts. http://bea.gov/regional/reis/ BEA data were used for total annual Social Security benefits rather than the figures available from the SSA in order to be consistent with the denominator of “Personal income,” which came from BEA. For other purposes in the report, such as calculating the average benefit and average retirement benefit in rural counties, SSA data were used. Social Security Beneficiaries by Characteristic: Social Security Administration (SSA), “Table 4. Number of beneficiaries in current-payment status, by county, type of benefit, and sex of beneficiaries aged 65 or older, December 2010,” OASDI Beneficiaries by State and County, 2010, June 2011. http://www.ssa.gov/policy/docs/statcomps/oasdi_sc/2010/index.html Percentage of Population receiving Medicare: Center for Medicare and Medicaid Services (CMS), “Beneficiaries Receiving Medicare: Total Beneficiaries by State and County,” 2010. http://www.cms.gov/ResearchStatistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareEnrpts/Downloads/County2010.pdf

18

endnotes
1 Complete citations for the sources of the numbers included in Figure 1 can be found where the numbers appear elsewhere in the report. All of the statistical data used in Figure 1, as well as the rest of the report, are the most current data available. Some data were available in more recent years than others. For sets of data partially available for one year and partially available for another, the most recent common year was chosen. As a result, nearly all numbers relating to Social Security date to 2010, nearly all numbers relating to Medicare date to 2009, and nearly all numbers relating to Medicaid date to FY2009. When data from other years are used, the report says so explicitly. 2 While Social Security and Medicare benefits are funded entirely by the federal government, Medicaid is partially funded by state governments, and sometimes local governments. 3 There were 56 million beneficiaries nationwide as of May 2012. Except where otherwise noted, the rest of the Social Security data referenced in this report date to 2010, the most recent common year in which those data were available. Total Social Security beneficiaries in individual states dating to 2010 will not add up to this figure. Social Security Administration (SSA), “Table 2. Social Security Benefits, May 2012,” Monthly Statistical Snapshot, May 2012, June 2012. http://www.ssa.gov/policy/docs/quickfacts/stat_snapshot/#table2 4 Average annual benefit amounts calculated by dividing total annual benefits by total beneficiaries. Total annual benefits from SSA, “Table 5. J1‐Estimated total annual benefits paid, by state or other area and program, 2010 (in millions of dollars),” Annual Statistical Supplement, 2011 [herein, Ann. Stat. Supp.], February 2012. http://www.ssa.gov/policy/docs/statcomps/supplement/2011/5j.html#table5.j2 Total beneficiaries from SSA, “Table 5. J2‐Number, by state or other area, program, and type of benefit, December 2010,” Ann. Stat Supp., February 2012. http://www.ssa.gov/policy/docs/ statcomps/supplement/2011/5j.html#table5.j1 5 Households refers to “aged units,” which are married couples living together of whom at least one is aged 65 or older, or unmarried persons aged 65 or older. SSA, Table 9.A1, Income of the Population, 55 or Older, 2010, August 2012. http://www.ssa.gov/policy/docs/statcomps/income_pop55/2010/ sect09.html#table9.a1 6 Center on Budget & Policy Priorities (CBPP), “Social Security Keeps 20 Million Americans Out of Poverty, A State-by-State Analysis,” August, 2010. http://www.cbpp.org/files/8-11-10socsec.pdf 7 Social Security Trustees, 2012 Annual Trustees Report, April 25, 2012, p. 11. http://www.ssa.gov/oact/tr/2012/tr2012.pdf 8 CBPP, “What the 2012 Trustees Report Shows About Social Security,” Figure 1, May 10, 2012. http://www.cbpp.org/cms/index. cfm?fa=view&id=3774 9 White House, Office of Management and Budget, Table 1.1 Summary of Receipts, Outlays and Surpluses or Deficits: 1789-2017, 2012. http://www. whitehouse.gov/omb/budget/Historicals 10 Social Security does not contribute to the deficit, because benefits can only be paid from revenue collected by the Social Security trust funds—the Old-Age and Survivors Insurance (OASI) trust fund and Disability Insurance (DI) trust fund—which are completely separate from the general budget. Social Security Trustees, Table II.B1, 2012 Annual Trustees Report, April 25, 2012, p. 6. http://www.ssa.gov/oact/tr/2012/tr2012.pdf In 2010 and 2011 The General Fund transferred money to the Social Security trust funds in order to replace revenue lost due to a temporary two-percentage-point payroll tax reduction. The payroll tax cut, and the General Fund transfer that resulted, was a temporary stimulus measure that will expire at the end of the year. It never fundamentally changed Social Security’s self-sustaining funding structure. The trust funds do not have borrowing authority, and therefore, cannot deficit-spend. In the event that trust fund revenues fall short of what is needed to pay 100 percent of benefits, then, by law, benefits could not be paid in full and on time. That is why, if Congress does nothing to shore up the program’s finances by 2033, Social Security will only have sufficient revenue to pay about three-quarters of scheduled benefits through 2086. Social Security Trustees, Table II.B1, 2012 Annual Trustees Report, April 25, 2012, p. 11. http://www.ssa.gov/oact/tr/2012/tr2012.pdf This modest funding shortfall is often cited as evidence that the program is financially unsustainable, or “in deficit.” In fact, it is just the opposite: it attests to Social Security’s self-sustaining funding structure that bars it from deficit-spending or borrowing from the general budget in any way. 11 Total beneficiaries from SSA, “Table 5.J2‐Number, by state or other area, program, and type of benefit, December 2010,” Ann. Stat. Supp., February 2012. http://www.ssa.gov/policy/docs/statcomps/supplement/2011/5j.html#table5.j2 State population data from U.S. Census Bureau, “Profile of General Population and Housing Characteristics: 2010,” 2010 Demographic Profile Data, 2011. http://factfinder2.census.gov/faces/tableservices/jsf/ pages/productview.xhtml?pid=DEC_10_DP_DPDP1&prodType=table 12 Total annual benefits from SSA, “Table 5.J1‐Estimated total annual benefits paid, by state or other area and program, 2010 (in millions of dollars),”‐ Ann. Stat. Supp., February 2012. http://www.ssa.gov/policy/docs/statcomps/supplement/2011/5j.html#table5.j1 Benefits’ equivalent percentage of Gross Domestic Product (GDP) calculated using state GDP figures from Bureau of Economic Analysis, “Gross Domestic Product by State (millions of current dollars),” September 29, 2011. http://bea.gov/iTable/iTable.cfm?ReqID=70&step=1&isuri=1&acrdn=1 13 Average benefit found by dividing total spending by total beneficiaries. Total annual benefits from Social Security Administration (SSA), “Table 5. J1‐Estimated total annual benefits paid, by state or other area and program, 2010 (in millions of dollars),” Ann. Stat. Supp., February 2012. http://www. ssa.gov/policy/docs/statcomps/supplement/2011/5j.html#table5.j1 Total beneficiaries from SSA, “Table 5.J2‐Number, by state or other area, program, and type of benefit, December 2010,” Ann. Stat. Supp., February 2012. http://www.ssa.gov/policy/docs/statcomps/supplement/2011/5j.html#table5.j2 14 CBPP, “Social Security Keeps 20 Million Americans Out of Poverty, A State-by-State Analysis,” August, 2010. http://www.cbpp.org/files/8-1110socsec.pdf Total number of state residents lifted out of poverty, which does not appear in CBPP’s report, was made available to Social Security Works by the report’s authors, Arloc Sherman and Paul N. Van de Water. The state-level data reflect an average from 2006-2008, and therefore do not add up to the national totals, which date to 2008. 15 For the purposes of this analysis, “seniors” describes individuals aged 65 or older. Herein, all references to “seniors” will reflect this definition. 16 SSA, “Table 5.J2—Number, by state or other area, program and type of benefit, December 2010,” Ann. Stat. Supp., February 2012. http://www.ssa. gov/policy/docs/statcomps/supplement/2011/5j.html#table5.j2 17 For the purposes of this analysis, “typical” is used to describe the “median” benefit. Herein, all references to “typical” will reflect this description. Monthly median benefit multiplied by 12 to calculate annual figure. SSA, “Table 5.J6—Percentage distribution of monthly benefit for retired workers, by state or other area and monthly benefit, December 2010,” Ann. Stat. Supp., February 2012. http://www.ssa.gov/policy/docs/statcomps/ supplement/2011/5j.html#table5.j6 18 SSA, “Table 5.J2—Number, by state or other area, program, and type of benefit, December 2010,” Ann. Stat. Supp., February 2012. http://www.ssa. gov/policy/docs/statcomps/supplement/2011/5j.html#table5.j2 19 CBPP, “Social Security Keeps 20 Million Americans Out of Poverty, A State-by-State Analysis,” August, 2010. http://www.cbpp.org/files/8-1110socsec.pdf The state-level data reflect an average from 2006-2008, and therefore do not add up to the national totals, which date to 2008.

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20 CBPP, “Social Security Keeps 20 Million Americans Out of Poverty, A State-by-State Analysis,” August, 2010. http://www.cbpp.org/files/8-1110socsec.pdf The state-level data reflect an average from 2006-2008, and therefore do not add up to the national totals, which date to 2008. 21 SSA, “Table 5.J5.1—Number, by state or other area, race, and sex, December 2010,” Ann. Stat. Supp., February 2012. http://www.ssa.gov/policy/ docs/statcomps/supplement/2011/5j.html#table5.j5.1 Percentage of women receiving benefits calculated using total female population from U.S. Census Bureau, “Age groups and Sex: 2010,” 2010 Census Summary File 2. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview. xhtml?pid=DEC_10_SF1_QTP1&prodType=table 22 SSA, “Table 5.J2—Number, by state or other area, program, and type of benefit, December 2010,” Ann. Stat. Supp., February 2012. http://www.ssa. gov/policy/docs/statcomps/supplement/2011/5j.html#table5.j2 23 CBPP, Ibid. The number and percentage of women aged 65 or older lifted out of poverty, which do not appear in CBPP’s report, were made available by the report’s authors, Arloc Sherman and Paul N. Van de Water. The state-level data reflect an average from 2006-2008, and therefore do not add up to the national totals, which date to 2008. 24 CBPP, Ibid. The number and percentage of women aged 65 or older lifted out of poverty, which do not appear in CBPP’s report, were made available by the report’s authors, Arloc Sherman and Paul N. Van de Water. The state-level data reflect an average from 2006-2008, and therefore do not add up to the national totals, which date to 2008. 25 The number of Social Security disability beneficiaries cited here includes only those disabled workers receiving disability benefits. It does not include those disabled workers and “disabled adult children” who receive Old-Age (retirement) and Survivors benefits. Herein, any use of the term “disabled worker” will refer only to those disabled workers receiving disability benefits. 26 SSA, “Table 5.J8—Percentage distribution of disabled workers, by state or other area and monthly benefit, December 2010,” Ann. Stat. Supp., February 2012. http://www.ssa.gov/policy/docs/statcomps/supplement/2011/5j.html#table5.j8 27 Monthly median benefit multiplied by 12 to calculate annual figure. SSA, Ibid. 28 Unless otherwise specified as children under 18 to the exclusion of all others, the term “children” used in this section is consistent with the Social Security Administration’s use of the term to include three groups: “children under age 18;” “students aged 18-19,” which refers to children ages 18 and 19 who are matriculated in an institution of secondary education; and “disabled adult children,” which refers to those adults who have been disabled since before they reached age 18. 29 U.S. Census Bureau, “Age Groups and Sex: 2010,” 2010 Summary File 2, 2011. http://factfinder2.census.gov/faces/tableservices/jsf/pages/ productview.xhtml?pid=DEC_10_SF2_QTP1&prodType=table Data on percentage of children insured from SSA, “Survivors Benefits,” 2011, p. 4. http:// ssa.gov/pubs/10084.pdf 30 SSA, “Table 5.J10—Number of children, by state or other area and type of benefit, December 2010,” Ann. Stat. Supp., February 2012. http://www. ssa.gov/policy/docs/statcomps/supplement/2011/5j.html#table5.j10 31 Association of American Retired Persons (AARP), “Grandfacts: State fact sheets for grandparents and other relatives raising children,” 2011. http:// www.aarp.org/relationships/friends-family/grandfacts-sheets/ 32 SSA, “Table 5.J5.1—Number, by state or other area, race, and sex, December 2009,” Annual Statistical Supplement, 2010, 2010. http://www.ssa. gov/policy/docs/statcomps/supplement/2010/5j.html#table5.j5.1 African American population from U.S. Census Bureau, “Selected Population Profile in the United States,‐ 2007-2009 American Community Survey 3-Year Estimates. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview. xhtml?pid=ACS_09_3YR_S0201&prodType=table 33 SSA, Table 9.A3, Income of the Population 55 or Older, 2010, March 2012. http://www.ssa.gov/policy/docs/statcomps/income_pop55/2010/sect09. html#table9.a3 34 SSA, “Table 5.A1‐Number and average monthly benefit, by type of benefit and race, December 2009,‐ Annual Statistical Supplement, 2010, February 2011. http://www.ssa.gov/policy/docs/statcomps/supplement/2010/5a.html#table5.a1 35 The term “households” as it is used here refers to households reporting income in the past 12 months. Households receiving Social Security benefits are those households listed as receiving “Social Security income.” U.S. Census Bureau, “Selected Population Profile,” 2008-2010 American Community Survey 3-Year Estimates. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_10_3YR_S0201&prodType=table 36 SSA, Table 9.A3, Income of the Population 55 or Older, 2010, March 2012. http://www.ssa.gov/policy/docs/statcomps/income_pop55/2010/sect09. html#table9.a3 37 SSA, “Social Security is Important to Hispanics,” January 2012. http://www.ssa.gov/pressoffice/factsheets/hispanics-alt.pdf 38 The term “households” as it is used here refers to households reporting income in the past 12 months. Households receiving Social Security benefits are those households listed as receiving “Social Security income.” U.S. Census Bureau, “Selected Population Profile,” 2008-2010 American Community Survey 3-Year Estimates, 2011. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_10_3YR_ S0201&prodType=table 39 SSA, “Social Security is Important to American Indians and Alaska Natives,” January 2012. http://www.ssa.gov/pressoffice/factsheets/amerindian-alt.pdf 40 SSA, “Social Security is Important to American Indians and Alaska Natives,” January 2012. http://www.ssa.gov/pressoffice/factsheets/amerindian-alt.pdf 41 The term “households” as it is used here refers to households reporting income in the past 12 months. Households receiving Social Security benefits are those households listed as receiving “Social Security income.” For states in which there are large numbers of Asian American residents as well as Native Hawaiian and Pacific Islander residents, the numbers of beneficiaries and residents were added to calculate percentage of total Asian American, Native Hawaiian and Pacific Islander residents receiving benefits. U.S. Census Bureau, “Selected Population Profile,” 2008-2010 American Community Survey 3-Year Estimates, 2011. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_10_3YR_ S0201&prodType=table 42 SSA, Table 9.A3, Income of the Population 55 or Older, 2010, March 2012. http://www.ssa.gov/policy/docs/statcomps/income_pop55/2010/sect09. html#table9.a3 43 SSA, “Social Security is Important to Asian Americans and Pacific Islanders,” January 2012. http://www.ssa.gov/pressoffice/factsheets/asian-alt.pdf 44 U.S. Department of Agriculture’s Economic Research Service (ERS), designates counties as rural or urban based on population density, grading them on a scale of 1 to 9, with 1 being the most urban and 9 being the most rural. Counties are considered rural if they are designated 4 or higher. For the purposes of this report, the authors used both the ERS’s 9-point scale, and the binary abbreviation of these codes, which codes rural counties “0” and urban counties “1.” 45 County-level population data from U.S. Census Bureau, “Profile of General Population and Housing Characteristics: 2010,” 2010 Demographic Profile Data. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=DEC_10_DP_DPDP1&prodType=table Beneficiary data from SSA, “Table 4. Number of beneficiaries in current payment status, by county, type of benefit, and sex of beneficiaries aged 65 or older, December 2010,” OASDI Beneficiaries by State and County, 2010, August 2011. http://www.ssa.gov/policy/docs/statcomps/oasdi_sc/index.html

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46 Total personal income: Bureau of Economic Analysis (BEA), Regional Economic Accounts: Local Area Personal Income, “Personal income” in CA 05N Personal income by major source and earnings by NAICS industry. http://bea.gov/regional/reis/ Social Security income: BEA, Regional Economic Accounts: Local Area Personal Income, “Old-age, Survivors and Disability insurance (OASDI) benefits” in CA 35 Personal current transfer receipts. http://bea.gov/regional/reis/ BEA data were used for total annual Social Security benefits rather than the figures available from the SSA in order to be consistent with the denominator of “Personal income,” which came from BEA. For other purposes in the report, such as calculating the average benefit and average retirement benefit in rural counties, SSA data were used. 47 SSA, Office of the Chief Actuary, Robert Baldwin and Sharon Chu. “Actuarial Note 2011.6: A Death and Disability Life Table for Insured Workers Born in 1991,” February 2012. The term “retirement age” refers to the Full Retirement Age at which workers become eligible for full retirement benefits for Social Security. http://www.ssa.gov/OACT/NOTES/ran6/index.html 48 SSA, Office of the Chief Actuary, Orlo R. Nichols, “The Insurance Value and Potential Survivor and Disability Benefits for an Illustrative Worker,” Memo to Alice Wade, Deputy Chief Actuary of Social Security, August 2008. http://socialsecurity-works.org/wp-content/uploads/2012/03/Illustrative_ Survivor_and_Disabilitycase_2008.pdf 49 National Academy of Social Insurance (NASI), “Medicare Finances: Findings of the 2012 Trustees Report,” April 2012, p. 1. http://www.nasi.org/sites/ default/files/research/Medicare_Finances_Findings_of_the_2012_Trustees_Report.pdf 50 Kaiser Family Foundation (KFF), “Projecting Income and Assets: What Might the Future Hold for the Next Generation of Medicare Beneficiaries?” June 2011. http://www.kff.org/medicare/upload/8172.pdf 51 Social Security Works calculation based on projected out-of-pocket health care costs in 2014 under current law, and projected Social Security benefits of retired worker with average earnings of $43,560. Out-of-pocket costs projection from KFF, Raising the Age of Medicare Eligibility: A Fresh Look Following Implementation of Health Reform, p. 9-10, July 2011. http://www.kff.org/medicare/upload/8169.pdf The estimated Social Security benefit is a projection for 2015, the closest date to 2014 available. Social Security Trustees, “Table VI.F10.—Annual Scheduled Benefit Amounts for Retired Workers With Various Pre-Retirement Earnings Patterns Based on Intermediate Assumptions, Calendar Years 2011-85,” 2011 Trustees Report, p. 201, May 13, 2011. http://www.ssa.gov/oact/tr/2011/tr2011.pdf 52 People with severe disabilities become eligible for Medicare coverage only after receiving Social Security Disability Insurance (DI) benefits for 24 months. People with End-Stage-Renal Disease (ESRD) and Lou Gehrig’s disease become eligible for Medicare as soon as they qualify for Medicare. Kaiser Family Foundation (KFF), Medicare: a Primer, April 2010, p. 2. http://www.kff.org/medicare/upload/7615-03.pdf 53 There were 48.7 million beneficiaries nationwide in 2011. Except where otherwise noted, the rest of the Medicare data referenced in this report date to 2009, the most recent common year in which those data were available. Total Medicare beneficiaries in individual states dating to 2009 will not add up to this figure. Medicare Trustees, 2012 Medicare Trustees Report, April 23, 2012, p. 6. http://www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2012.pdf 54 Average expenditure per beneficiary is “average benefit per enrollee.” Figure does not include administrative expenditures per enrollee. Medicare Trustees, “Table II.B1—Medicare Data for Calendar Year 2011,” 2012 Trustees Report, April 2012, p. 10. http://www.cms.gov/Research-Statistics-Dataand-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2012.pdf 55 KFF, Medicare: a Primer, April 2010, p. 1. http://www.kff.org/medicare/upload/7615-03.pdf 56 KFF, Ibid. 57 Medicare Payment Advisory Board (Medpac), Report to the Congress: Medicare Payment Policy, Chapter 4, March 2010. http://www.medpac.gov/ chapters/Mar10_Ch04.pdf 58 White House, Office of the Press Secretary, “The Affordable Care Act: Strengthening Medicare, Combating Misinformation and Protecting America’s Senior,” June 8, 2010. http://www.whitehouse.gov/the-press-office/affordable-care-act-strengthening-medicare-combating-misinformation-andprotecting59 White House, Office of the Press Secretary, Ibid. 60 KFF, Medicare: a Primer, April 2010, p. 1. http://www.kff.org/medicare/upload/7615-03.pdf Percentage of total Medicare beneficiaries enrolled in Medicare Advantage calculated using total Medicare beneficiaries figure for 2010 in source. 61 KFF, Ibid. Percentage of total Medicare beneficiaries enrolled in Medicare Advantage calculated using total Medicare beneficiaries figure for 2010 in source. 62 Center for Medicare & Medicaid Services (CMS), Table 13, National Health Expenditure Data. https://www.cms.gov/nationalhealthexpenddata/ downloads/tables.pdf Presentation of data done according to the method employed by Jacob S. Hacker for Figure 2 in The Case for Public Plan Choice in National Health Reform, 2009. http://institute.ourfuture.org/files/Jacob_Hacker_Public_Plan_Choice.pdf 63 Hacker, The Case for Public Plan Choice in National Health Reform, 2009, p. 6. http://institute.ourfuture.org/files/Jacob_Hacker_Public_Plan_Choice.pdf 64 Table II.B1—Medicare Data for Calendar Year 2011,” 2012 Trustees Report, April 2012, p. 10. http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2012.pdf Figure reflects total administrative expenses of Medicare Parts A, B, and D, but not Part C, for which that information was not available. 65 Congressional Budget Office (CBO), “Key Issues in Analyzing Major Health Insurance Proposals,” December 2008, p. 70. http://www.cbo.gov/ ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf 66 CBO, Ibid, p. 94. http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf 67 Medicare Advantage’s administrative costs are expected to decline from the figure cited above as a result of reforms passed in the Patient Protection and Affordable Care Act (ACA) of March 2010. CBO, “Designing a Premium Support System for Medicare,” December 2006, p. 12. http:// www.cbo.gov/ftpdocs/76xx/doc7697/12-08-Medicare.pdf 68 KFF, “Medicare Spending Estimates by State of Residence (in millions), 2009,” December 2011. http://www.statehealthfacts.org/comparemaptable. jsp?ind=620&cat=6 Total health care spending from: KFF, “Health Care Expenditures by State of Residence (in millions), 2009,” December 2011. http:// www.statehealthfacts.org/comparemaptable.jsp?ind=592&cat=5 69 Average benefit found by dividing total spending by total beneficiaries. KFF, “Medicare Spending Estimates by State of Residence (in millions), 2009,” December 2011. http://www.statehealthfacts.org/comparemaptable.jsp?ind=620&cat=6 KFF, “Total Number of Medicare Beneficiaries, 2009,” 2010. http://www.statehealthfacts.org/comparemaptable.jsp?yr=92&typ=1&ind=290&cat=6&sub=74 70 KFF, “Total Number of Medicare Beneficiaries, 2009,” 2010. http://www.statehealthfacts.org/comparemaptable.jsp?yr=92&typ=1&ind=290&cat=6&s ub=74 State population data from U.S. Census Bureau, “General Demographic Characteristics,” 2009 Population Estimates. http://factfinder2.census. gov/faces/tableservices/jsf/pages/productview.xhtml?pid=PEP_2009_DP1&prodType=table 71 KFF, “Distribution of Medicare Beneficiaries by Eligibility Category, 2009,” 2010. http://www.statehealthfacts.org/comparetable.jsp?ind=293&cat=6 2009 was the most current year with data available on the breakdown of Medicare beneficiaries by category.

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72 KFF, “Distribution of Medicare Beneficiaries by Eligibility Category, 2009,” 2010. http://www.statehealthfacts.org/comparetable.jsp?ind=293&cat=6 2009 was the year with the most current data available on the breakdown of Medicare beneficiaries by category. 73 National Institutes of Health, U.S. National Library of Medicine (NLM), “End-stage kidney disease,” 2011. http://www.nlm.nih.gov/medlineplus/ency/ article/000500.htm 74 NLM, “Amyotrophic Lateral Sclerosis,” 2011. http://www.nlm.nih.gov/medlineplus/amyotrophiclateralsclerosis.html 75 KFF, Medicaid: a Primer, June 2010, p. 3. http://www.kff.org/medicaid/upload/7334-04.pdf 76 In the case of Medicaid, “2009” refers to data from FY2009. Except where otherwise noted, Medicaid data referenced in this report date to FY2009, the most recent common year in which those data were available. KFF, “Total Medicaid Enrollment FY2009,” 2012. http://www.statehealthfacts.org/ comparemaptable.jsp?ind=198&cat=4 77 KFF, Employer Health Benefits: 2011 Annual Survey, September 27, 2012, p. 1. http://ehbs.kff.org/pdf/2011/8225.pdf 78 KFF, Medicaid: a Primer, June 2010, p. 23. http://www.kff.org/medicaid/upload/7334-04.pdf 79 Families USA, Tables 1-2, Cutting Medicaid: Harming Seniors and People with Disabilities Who Need Long-Term Care, May 2011, pp. 3-4. http://familiesusa2.org/assets/pdfs/long-term-care/Cutting-Medicaid.pdf 80 KFF, Medicaid: a Primer, June 2010, p. 23. http://www.kff.org/medicaid/upload/7334-04.pdf 81 KFF, Medicaid: a Primer, June 2010, p. 1. http://www.kff.org/medicaid/upload/7334-04.pdf 82 As noted previously, aside from the total national Medicaid enrollees included in the introduction of the Medicaid section of this report, all Medicaid figures, unless otherwise noted, date to FY2009, the most recent common year in which data were available. KFF, “Total Medicaid Spending, FY2009,” 2012, Unpublished; Data provided to Social Security Works by Lindsay Donaldson, Research Associate at the Kaiser Family Foundation. Medicaid’s percent of total health care found by dividing total Medicaid spending by total health care expenditures. KFF, “Health Care Expenditures by State of Residence (in millions), 2009”, 2010. http://www.statehealthfacts.org/comparemaptable.jsp?ind=592&cat=5 Medicaid spending figure includes portion of funding that comes from state and local governments. 83 Average found by dividing total spending by total beneficiaries. KFF, “Total Medicaid Spending, FY2009,” 2012, Unpublished; Data provided to Social Security Works by Lindsay Donaldson, Research Associate at the Kaiser Family Foundation. KFF, “Total Medicaid Beneficiaries 2009”, 2010. http://www.statehealthfacts.org/comparetable.jsp?ind=198&cat=4 84 KFF, “Total Medicaid Enrollment FY 2009,” 2012. http://www.statehealthfacts.org/comparetable.jsp?ind=198&cat=4 State population data from U.S. Census Bureau, “General Demographic Characteristics,” 2009 Population Estimates. http://factfinder2.census.gov/faces/tableservices/jsf/pages/ productview.xhtml?pid=PEP_2009_DP1&prodType=table 85 KFF, “Distribution of Medicaid Enrollees by Enrollment Group, FY2009,” 2012. http://www.statehealthfacts.org/comparemaptable. jsp?ind=200&cat=4 Children’s population data from U.S. Census Bureau, “Children Characteristics,” 2009 American Community Survey 1-Year Estimates. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_09_1YR_S0901&prodType=table 86 KFF, “Distribution of Medicaid Enrollees by Enrollment Group, FY2009,” 2012. http://www.statehealthfacts.org/comparemaptable. jsp?typ=1&ind=200&cat=4&sub=52 87 KFF, “Distribution of Medicaid Enrollees by Enrollment Group, FY2009,” 2012. http://www.statehealthfacts.org/comparemaptable. jsp?typ=1&ind=200&cat=4&sub=52 88 KFF, “Medicaid Long-Term Care Funding by Category, FY2009,” 2012, Unpublished; Data provided to Social Security Works by Lindsay Donaldson, Research Associate at the Kaiser Family Foundation. 89 Data on Medicaid’s coverage of nursing home residents, as well as the cost of nursing home rooms in each state, date to 2010. Had 2009 data been available, they would have been used for the sake of consistency with the other state-level benefit and beneficiary data. Families USA, Table 3, Cutting Medicaid: Harming Seniors and people With Disabilities Who Need Long-Term Care, May 2011. http://familiesusa2.org/assets/pdfs/long-term-care/ Cutting-Medicaid.pdf 90 Families USA, Table 5, Cutting Medicaid: Harming Seniors and people With Disabilities Who Need Long-Term Care, May 2011. http://familiesusa2. org/assets/pdfs/long-term-care/Cutting-Medicaid.pdf 91 KFF, Medicaid: a Primer, June 2010, p. 25. 92 Center for Economic and Policy Research (CEPR), “U.S. Budget Deficits 2001-2011.” Analysis of Congressional Budget Office data. First published here. 93 Medicare Trustees, 2012 Medicare Trustees Report, “Table II.B1—Medicare Data for Calendar Year 2011,” p. 10. Figure reflects total administrative expenses of Medicare Parts A, B, and D, but not Part C, for which that information was not available. Congressional Budget Office (CBO), “Key Issues in Analyzing Major Health Insurance Proposals,” December 2008, p. 70. http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf 94 Total benefits figure reflects the sum of total annual spending by Social Security, Medicare and Medicaid in the state, each of which are individually sourced in the report. Average ratio of residents receiving benefits from Social Security, Medicare or Medicaid, is an average of the percentages of residents receiving benefits from each of the three programs.

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key factS aBout Social Security, Medicare & Medicaid in MiSSouri
Social Security, Medicare and Medicaid work for Missouri residents of all ages and backgrounds. This report, Social Security, Medicare & Medicaid Work for Missouri shows that:

Social Security Works for Missouri’s Residents and Economy
• Social Security provided benefits to 1,166,223 Missourians in 2010, 1 out of 5 residents, including 725,690 retired workers, 202,465 disabled workers, 94,195 widow(er)s, 44,808 spouses, and 99,065 children. [Figure 3] • Social Security provided benefits totaling over $15 billion in 2010, an amount equivalent to 6.2 percent of the state’s annual GDP (the total value of all goods and services produced). • The average Social Security benefit in 2010 was $12,854. • Social Security lifted 487,000 Missouri residents out of poverty in 2008.

Social Security Works for Missouri’s Women
• Social Security provided benefits to 595,950 women residents in 2010, 1 out of 5 women. • Without Social Security, the poverty rate of elderly women would increase from 8.7 percent to 50 percent.

Social Security Works for Missouri’s People of Color
• Social Security provided benefits to 107,776 African Americans in Missouri in 2009, 1 out of 7 African American residents. • It provided benefits to 1 out of 7 Latino households in Missouri in 2010, 7,602 households.

Medicare Works for Missouri’s Residents and Economy
• 975,145 Missourians received Medicare benefits in 2009—1 out of 6 state residents. • Medicare provided $10 billion in benefits in 2009—23 percent of all health care spending in the state. The average expenditure per Medicare beneficiary was $9,826.

Medicare Works for Missouri’s Seniors and People with Disabilities
• 794,032 of Missouri’s 975,145 Medicare beneficiaries were aged 65 or older in 2009—8 out of 10 beneficiaries. • 182,382 of Missouri’s 975,145 Medicare beneficiaries were people with disabilities in 2009—1 out of 5 beneficiaries.

Medicaid Works for Missouri’s Residents and Economy
• 1,065,266 Missourians received Medicaid benefits in 2009—1 out of 6 state residents. • A total of $7.7 billion in Medicaid benefits were paid in 2009—18.6 percent of all health care spending in the state. The average expenditure per Medicaid beneficiary was $7,273.

Medicaid Works for Missouri’s Seniors, People with Disabilities and Long-Term Care Residents
• 94,318 of Missouri’s 1,065,266 Medicaid beneficiaries were aged 65 or older in 2009—1 out of 11 beneficiaries. • 203,645 of Missouri’s 1,065,266 Medicaid beneficiaries were people with disabilities in 2009—1 out of 5 beneficiaries. • Medicaid provided $1.9 billion in long-term care benefits for Missouri residents in 2009, including providing nursing home care for 23,000 nursing home residents, 2 out of 3 of state residents enrolled in nursing homes.

http://strengthensocialsecurity.org/statereports2012