This document provides a summary of findings from a report by the Committee on Oversight and Government Reform regarding the potential impacts of 7 Medicaid regulations proposed by CMS. Key findings include:
1) State estimates found the regulations could reduce federal Medicaid payments to states by $49.7 billion over 5 years, more than 3 times CMS's estimate of $15 billion.
2) The regulations are likely to shift costs from the federal government to states rather than improve efficiencies.
3) The regulations could disrupt care systems for vulnerable groups and threaten the stability of safety net hospitals and clinics treating uninsured patients.
4) The regulations would impose significant administrative burdens and costs on state Medicaid programs.
5
This document provides an overview of the US healthcare system. It discusses healthcare finance, including spending as a percentage of GDP and sources of insurance. It addresses healthcare access, such as barriers from lack of insurance or inadequate coverage. It also examines healthcare quality and compares the US system to other countries' public or socialized insurance models.
Medicaid May Allow States to Save Millions on Prisoner Medical CareJamie A. Brennan
This article discusses how states may be able to save millions of dollars in prisoner medical care costs by taking advantage of a 1997 Medicaid rule. The rule allows states to enroll prisoners in Medicaid and receive federal matching funds for hospital costs over $24 hours if the prisoners qualify financially. With the expansion of Medicaid under the ACA, many more prisoners likely meet eligibility requirements. The article recommends states research this opportunity and develop agreements between Medicaid and corrections agencies to implement enrollment of eligible prisoners in Medicaid to help reduce rising medical costs for prisoners.
This chapter provides an overview of economics concepts relevant to health policy and discusses key provisions of the Affordable Care Act. It covers demand, supply, markets, and why health reform is difficult in the US. It then summarizes previous reform attempts and the major ACA provisions, including the individual mandate, state exchanges, subsidies, employer requirements, insurance regulations, and financing mechanisms.
- Healthcare costs in the US have rapidly increased since the mid-20th century, with spending reaching $2.8 trillion in 2012. Despite high costs, the US healthcare system ranks poorly on outcomes.
- Oregon implemented Coordinated Care Organizations (CCOs) in 2012 to contain Medicaid costs and improve outcomes. CCOs receive a fixed global budget to provide coordinated care through integrated networks.
- Early results show CCOs have decreased emergency room visits and hospitalizations while increasing primary care spending. This shift to preventative care is expected to further reduce costs and improve patient health over time.
The document discusses deficiencies in the Affordable Care Act related to Medicaid eligibility and funding. It argues that Medicaid eligibility should be expanded to cover more low-income individuals and families. Specifically, it states that the eligibility criteria should be changed to just below the income level of the middle class. It also argues that the government needs to better manage healthcare spending and could generate new funding by legalizing and taxing marijuana, with states required to spend a percentage on Medicaid. This would help increase access to healthcare for low-income individuals.
This document provides an overview of the US healthcare system. It discusses healthcare finance, including spending as a percentage of GDP and sources of insurance. It addresses healthcare access, such as barriers from lack of insurance or inadequate coverage. It also examines healthcare quality and compares the US system to other countries' public or socialized insurance models.
Medicaid May Allow States to Save Millions on Prisoner Medical CareJamie A. Brennan
This article discusses how states may be able to save millions of dollars in prisoner medical care costs by taking advantage of a 1997 Medicaid rule. The rule allows states to enroll prisoners in Medicaid and receive federal matching funds for hospital costs over $24 hours if the prisoners qualify financially. With the expansion of Medicaid under the ACA, many more prisoners likely meet eligibility requirements. The article recommends states research this opportunity and develop agreements between Medicaid and corrections agencies to implement enrollment of eligible prisoners in Medicaid to help reduce rising medical costs for prisoners.
This chapter provides an overview of economics concepts relevant to health policy and discusses key provisions of the Affordable Care Act. It covers demand, supply, markets, and why health reform is difficult in the US. It then summarizes previous reform attempts and the major ACA provisions, including the individual mandate, state exchanges, subsidies, employer requirements, insurance regulations, and financing mechanisms.
- Healthcare costs in the US have rapidly increased since the mid-20th century, with spending reaching $2.8 trillion in 2012. Despite high costs, the US healthcare system ranks poorly on outcomes.
- Oregon implemented Coordinated Care Organizations (CCOs) in 2012 to contain Medicaid costs and improve outcomes. CCOs receive a fixed global budget to provide coordinated care through integrated networks.
- Early results show CCOs have decreased emergency room visits and hospitalizations while increasing primary care spending. This shift to preventative care is expected to further reduce costs and improve patient health over time.
The document discusses deficiencies in the Affordable Care Act related to Medicaid eligibility and funding. It argues that Medicaid eligibility should be expanded to cover more low-income individuals and families. Specifically, it states that the eligibility criteria should be changed to just below the income level of the middle class. It also argues that the government needs to better manage healthcare spending and could generate new funding by legalizing and taxing marijuana, with states required to spend a percentage on Medicaid. This would help increase access to healthcare for low-income individuals.
The document provides one-page summaries of responses from 43 state Medicaid Directors and Washington D.C. on the impact of 7 recent Medicaid regulations. For each state, the summaries include estimates of lost federal funds in 2008 and over 5 years for regulations limiting payments to public providers, graduate medical education, outpatient hospital services, provider taxes, coverage of rehabilitative services, payments for school services, and targeted case management. Quotes from each state convey concerns about reduced access to care, loss of providers and services, and increased costs.
Integrating Care for Dual Eligibles: Capitated Managed Care OptionsNASHP HealthPolicy
This document discusses options for states to integrate care for dual eligible Medicaid and Medicare beneficiaries through capitated managed care plans. It provides background on dual eligibles and states' experiences using Special Needs Plans (SNPs) and other models to provide coordinated care. A few key points: about 12% of dual eligibles are enrolled in comprehensive Medicaid managed care plans, while around 5% are enrolled in Medicare Advantage plans; several states have developed integrated programs using SNPs, though enrollment and coordination challenges remain; and long-term services and supports represent major opportunities and challenges for managed care programs serving duals.
This chapter overview describes the goals and essential services of public health institutions and systems in the United States. It identifies the roles of local, state, and federal public health agencies, as well as global health organizations. It also illustrates the need for collaboration between governmental and non-governmental organizations to achieve public health goals.
This document discusses public health preparedness and policy. It describes public health preparedness as the ability to prevent, respond to, and recover from health emergencies that could overwhelm routine capabilities. Public health emergencies include intentional or accidental chemical/biological/radiological/nuclear releases, natural epidemics/pandemics, natural disasters, and environmental disasters. Key federal agencies related to preparedness policy include the Office of the Assistant Secretary for Preparedness and Response, CDC, NIH, FDA, USDA, FBI, DOD. Preparedness requires cooperation among federal, state, and local governments according to their respective responsibilities.
The article discusses proposals to reform Medicaid in the U.S., including the House bill that would cap federal Medicaid funding. This could lead to a 26% reduction in federal support by 2026 and unprecedented financial risk shifting to states. The article argues that Medicaid reform proposals should consider the realities of the program, including that most enrollees and spending are for non-disabled adults, children, and older/disabled adults. It suggests bipartisan reforms could focus on increasing state flexibility, integrating physical and behavioral healthcare, and addressing high prescription drug costs. Overall, the greatest benefits will come from acknowledging Medicaid's successes and weaknesses to pursue tailored policies.
Universal Health Care in the United StatesShantanu Basu
The document discusses the current US healthcare system and theories of policy change. It analyzes how multiple problem streams, political conditions, and policy alternatives could converge to place healthcare reform on the policy agenda. Specifically, rising costs, decreased coverage, and poor outcomes have highlighted issues with the current system. Shifting public opinion and the upcoming presidential election may open a policy window to address universal healthcare.
Health Care Reform Goes Live: The Affordable Care Act in 2014Craig B. Garner
The document provides an overview of health care reform under the Affordable Care Act (ACA) that goes into effect in 2014. It summarizes the history of health care in the US and the key provisions of the ACA, including the individual and employer mandates, health insurance exchanges, essential health benefits, and reforms to the delivery of medical care through programs like Accountable Care Organizations. The document is intended to educate about how the ACA will be implemented and its impact on various groups in early 2014.
National Health Care Reform: The Proposals and the Politicssoder145
Presentation by Elizabeth Lukanen at the University of Minnesota Academic Health Center's Student Leadership Summit in Minneapolis, MN, December 5, 2009.
While the health care reform bill is a step in the right direction, medicare for all or single payer is what is really needed to control costs and insure all.
How doctors could rescue health care by arnold relman | the new york review o...Carlo Favaretti
The document summarizes the challenges facing the US healthcare system, including rapidly rising costs that are unsustainable. It argues that the Affordable Care Act is unlikely to significantly reduce costs due to flaws like not addressing the high overhead of private insurers, fee-for-service payment incentives, and fragmented care. Proposed programs in the Act like Accountable Care Organizations and an Independent Payment Advisory Board face obstacles. Major reforms are still needed to control healthcare spending.
The document discusses the different types of health insurance in the United States. The majority (49%) have private insurance through their employer, while 13% have Medicare, 18% have Medicaid, and 11% are uninsured. Medicare covers those over 65 and is run by the federal government, while Medicaid provides coverage for low-income families and is administered by each state. Private insurance through an employer is most common but may not cover all conditions, and individual plans are increasingly expensive, contributing to the number of uninsured.
The document summarizes concerns from Kansas legislators about additional state spending required by federally funded programs. It notes that in fiscal year 2016, Kansas agencies will need to spend an estimated $2 billion on cost-sharing obligations for over 500 federal programs. It also discusses conditions placed on federal funds, penalties for noncompliance, and how some national policies have been tied to federal funding with mixed legal challenges. The Supreme Court ruled that Medicaid expansion in the Affordable Care Act was coercively tied to all federal Medicaid funds.
IHC -- Health reform: What it means and what's nextGalen Institute
This document summarizes key points about the current state of health reform and what may happen next:
- The Affordable Care Act aims to expand coverage to 32 million more Americans but 23 million will remain uninsured. It establishes insurance mandates and exchanges and cuts Medicare spending.
- While early benefits of the law are popular, the law remains unpopular due to concerns about higher costs for taxpayers and consumers. Up to 80 million Americans could be forced to change their health plans.
- Implementation of the law faces challenges through legal challenges, heavy regulation, and political debates during the 2012 election.
- Opportunities exist to reshape the policy debate and push for a more dynamic, personalized system that engages
This document summarizes public opinion and analysis surrounding the Affordable Care Act (ACA) or "Obamacare". [1] Most Americans believe the ACA will increase taxes, the federal deficit, health care costs and premiums while decreasing quality. [2] The ACA faces widespread pushback from states resisting implementation and individuals concerned about lost choices and higher costs. [3] Studies show the law is failing to meet its goals of expanding coverage and lowering costs. Significant changes to the law seem inevitable as public opposition grows.
This document provides a summary of an AAFP Government Affairs Update presented in Dallas, TX on November 3, 2017. It introduces the AAFP Division of Government Relations staff and lists the AAFP's top issues for 2017, which include promoting physician payment reforms, defending gains in health insurance coverage, reducing administrative burdens, improving physician well-being, increasing the family physician workforce, and supporting population health improvement. Charts are included analyzing the current Congress and outlook for the 2018 Senate elections. The document reviews the status of key health care issues and upcoming deadlines under the Trump Administration.
Medicaid was established in 1965 under President Lyndon B. Johnson as a federal-state program to provide health coverage for low-income individuals and families. It has since expanded coverage to additional groups like children, pregnant women, the disabled, and the elderly. States administer their own Medicaid programs within federal minimum guidelines for eligibility and covered services. Both the federal and state governments jointly fund Medicaid, with the federal contribution varying by state based on per capita income. Over time, Medicaid has grown to cover over 60 million Americans and account for a significant portion of state budgets.
A Non-Random Walk Revisited: Short- and Long-Term Memory in Asset PricesPeter Ho
This paper examines the possibility of short- and long-term memory in international asset prices across 44 markets. Using random walk tests over multiple lags, the authors find mixed evidence of long memory, with some emerging markets and commodity/currency markets exhibiting long memory properties. Regression of a dummy variable indicates that markets with poorer risk-adjusted returns are more likely to reject the random walk hypothesis. Additionally, the choice of truncation lag in long memory tests is found to have little bearing on the results.
This document summarizes a paper that analyzes whether central banks should modify their interest rate policy rules (like the Taylor rule) to account for credit spreads or credit volumes. The paper uses a New Keynesian economic model modified to include financial frictions like heterogeneous households and credit markets. It finds that adjusting the policy rate in response to changes in credit spreads or volumes can improve outcomes in response to financial disturbances, but such adjustments may not help or could hurt in response to other disturbance types. The paper concludes by discussing the model and outlining the analysis that will be conducted using the model to evaluate modified policy rules.
The document provides one-page summaries of responses from 43 state Medicaid Directors and Washington D.C. on the impact of 7 recent Medicaid regulations. For each state, the summaries include estimates of lost federal funds in 2008 and over 5 years for regulations limiting payments to public providers, graduate medical education, outpatient hospital services, provider taxes, coverage of rehabilitative services, payments for school services, and targeted case management. Quotes from each state convey concerns about reduced access to care, loss of providers and services, and increased costs.
Integrating Care for Dual Eligibles: Capitated Managed Care OptionsNASHP HealthPolicy
This document discusses options for states to integrate care for dual eligible Medicaid and Medicare beneficiaries through capitated managed care plans. It provides background on dual eligibles and states' experiences using Special Needs Plans (SNPs) and other models to provide coordinated care. A few key points: about 12% of dual eligibles are enrolled in comprehensive Medicaid managed care plans, while around 5% are enrolled in Medicare Advantage plans; several states have developed integrated programs using SNPs, though enrollment and coordination challenges remain; and long-term services and supports represent major opportunities and challenges for managed care programs serving duals.
This chapter overview describes the goals and essential services of public health institutions and systems in the United States. It identifies the roles of local, state, and federal public health agencies, as well as global health organizations. It also illustrates the need for collaboration between governmental and non-governmental organizations to achieve public health goals.
This document discusses public health preparedness and policy. It describes public health preparedness as the ability to prevent, respond to, and recover from health emergencies that could overwhelm routine capabilities. Public health emergencies include intentional or accidental chemical/biological/radiological/nuclear releases, natural epidemics/pandemics, natural disasters, and environmental disasters. Key federal agencies related to preparedness policy include the Office of the Assistant Secretary for Preparedness and Response, CDC, NIH, FDA, USDA, FBI, DOD. Preparedness requires cooperation among federal, state, and local governments according to their respective responsibilities.
The article discusses proposals to reform Medicaid in the U.S., including the House bill that would cap federal Medicaid funding. This could lead to a 26% reduction in federal support by 2026 and unprecedented financial risk shifting to states. The article argues that Medicaid reform proposals should consider the realities of the program, including that most enrollees and spending are for non-disabled adults, children, and older/disabled adults. It suggests bipartisan reforms could focus on increasing state flexibility, integrating physical and behavioral healthcare, and addressing high prescription drug costs. Overall, the greatest benefits will come from acknowledging Medicaid's successes and weaknesses to pursue tailored policies.
Universal Health Care in the United StatesShantanu Basu
The document discusses the current US healthcare system and theories of policy change. It analyzes how multiple problem streams, political conditions, and policy alternatives could converge to place healthcare reform on the policy agenda. Specifically, rising costs, decreased coverage, and poor outcomes have highlighted issues with the current system. Shifting public opinion and the upcoming presidential election may open a policy window to address universal healthcare.
Health Care Reform Goes Live: The Affordable Care Act in 2014Craig B. Garner
The document provides an overview of health care reform under the Affordable Care Act (ACA) that goes into effect in 2014. It summarizes the history of health care in the US and the key provisions of the ACA, including the individual and employer mandates, health insurance exchanges, essential health benefits, and reforms to the delivery of medical care through programs like Accountable Care Organizations. The document is intended to educate about how the ACA will be implemented and its impact on various groups in early 2014.
National Health Care Reform: The Proposals and the Politicssoder145
Presentation by Elizabeth Lukanen at the University of Minnesota Academic Health Center's Student Leadership Summit in Minneapolis, MN, December 5, 2009.
While the health care reform bill is a step in the right direction, medicare for all or single payer is what is really needed to control costs and insure all.
How doctors could rescue health care by arnold relman | the new york review o...Carlo Favaretti
The document summarizes the challenges facing the US healthcare system, including rapidly rising costs that are unsustainable. It argues that the Affordable Care Act is unlikely to significantly reduce costs due to flaws like not addressing the high overhead of private insurers, fee-for-service payment incentives, and fragmented care. Proposed programs in the Act like Accountable Care Organizations and an Independent Payment Advisory Board face obstacles. Major reforms are still needed to control healthcare spending.
The document discusses the different types of health insurance in the United States. The majority (49%) have private insurance through their employer, while 13% have Medicare, 18% have Medicaid, and 11% are uninsured. Medicare covers those over 65 and is run by the federal government, while Medicaid provides coverage for low-income families and is administered by each state. Private insurance through an employer is most common but may not cover all conditions, and individual plans are increasingly expensive, contributing to the number of uninsured.
The document summarizes concerns from Kansas legislators about additional state spending required by federally funded programs. It notes that in fiscal year 2016, Kansas agencies will need to spend an estimated $2 billion on cost-sharing obligations for over 500 federal programs. It also discusses conditions placed on federal funds, penalties for noncompliance, and how some national policies have been tied to federal funding with mixed legal challenges. The Supreme Court ruled that Medicaid expansion in the Affordable Care Act was coercively tied to all federal Medicaid funds.
IHC -- Health reform: What it means and what's nextGalen Institute
This document summarizes key points about the current state of health reform and what may happen next:
- The Affordable Care Act aims to expand coverage to 32 million more Americans but 23 million will remain uninsured. It establishes insurance mandates and exchanges and cuts Medicare spending.
- While early benefits of the law are popular, the law remains unpopular due to concerns about higher costs for taxpayers and consumers. Up to 80 million Americans could be forced to change their health plans.
- Implementation of the law faces challenges through legal challenges, heavy regulation, and political debates during the 2012 election.
- Opportunities exist to reshape the policy debate and push for a more dynamic, personalized system that engages
This document summarizes public opinion and analysis surrounding the Affordable Care Act (ACA) or "Obamacare". [1] Most Americans believe the ACA will increase taxes, the federal deficit, health care costs and premiums while decreasing quality. [2] The ACA faces widespread pushback from states resisting implementation and individuals concerned about lost choices and higher costs. [3] Studies show the law is failing to meet its goals of expanding coverage and lowering costs. Significant changes to the law seem inevitable as public opposition grows.
This document provides a summary of an AAFP Government Affairs Update presented in Dallas, TX on November 3, 2017. It introduces the AAFP Division of Government Relations staff and lists the AAFP's top issues for 2017, which include promoting physician payment reforms, defending gains in health insurance coverage, reducing administrative burdens, improving physician well-being, increasing the family physician workforce, and supporting population health improvement. Charts are included analyzing the current Congress and outlook for the 2018 Senate elections. The document reviews the status of key health care issues and upcoming deadlines under the Trump Administration.
Medicaid was established in 1965 under President Lyndon B. Johnson as a federal-state program to provide health coverage for low-income individuals and families. It has since expanded coverage to additional groups like children, pregnant women, the disabled, and the elderly. States administer their own Medicaid programs within federal minimum guidelines for eligibility and covered services. Both the federal and state governments jointly fund Medicaid, with the federal contribution varying by state based on per capita income. Over time, Medicaid has grown to cover over 60 million Americans and account for a significant portion of state budgets.
A Non-Random Walk Revisited: Short- and Long-Term Memory in Asset PricesPeter Ho
This paper examines the possibility of short- and long-term memory in international asset prices across 44 markets. Using random walk tests over multiple lags, the authors find mixed evidence of long memory, with some emerging markets and commodity/currency markets exhibiting long memory properties. Regression of a dummy variable indicates that markets with poorer risk-adjusted returns are more likely to reject the random walk hypothesis. Additionally, the choice of truncation lag in long memory tests is found to have little bearing on the results.
This document summarizes a paper that analyzes whether central banks should modify their interest rate policy rules (like the Taylor rule) to account for credit spreads or credit volumes. The paper uses a New Keynesian economic model modified to include financial frictions like heterogeneous households and credit markets. It finds that adjusting the policy rate in response to changes in credit spreads or volumes can improve outcomes in response to financial disturbances, but such adjustments may not help or could hurt in response to other disturbance types. The paper concludes by discussing the model and outlining the analysis that will be conducted using the model to evaluate modified policy rules.
The document is a summary of the World Economic Outlook report from April 2009 published by the IMF. It discusses the state of the global economy during the financial crisis. The key points are:
1) The global economy contracted by 1.3% in 2009, the deepest post-World War II recession, with output declining in three-quarters of the global economy. Growth was projected to pick up to 1.9% in 2010 but remain sluggish.
2) Financial market stabilization was expected to take longer than previously thought, keeping financial conditions weak and reducing credit to the private sector in advanced economies in 2009-2010. Total global write-downs on assets could reach $4 trillion over two years.
The document provides an overview and outlook of the global economy in the aftermath of the global financial crisis. It discusses how the crisis has led to a sharp decline in global growth, private capital flows, commodity prices, and industrial production. It also examines the policy responses of countries and risks to recovery. Key challenges going forward include strengthening confidence, coordinating policies, and mitigating the crisis's impact on low-income countries. The outlook remains uncertain with downside risks including weak medium-term growth and the potential for balance of payments crises in countries with large financing needs.
This document presents an estimated arbitrage-free model that jointly models nominal and real US Treasury yields. It estimates separate arbitrage-free Nelson-Siegel models for nominal and real yields, finding a three-factor model fits nominal yields well and a two-factor model fits real yields. It then estimates a four-factor joint model that fits both yield curves. The joint model is used to decompose breakeven inflation rates into inflation expectations and inflation risk premium components.
Non-Performing Loans, Prospective Bailouts, and Japan’s SlowdownPeter Ho
This document discusses Japan's prolonged economic slowdown since the early 1990s and argues that the government's delay in bailing out financial institutions burdened with non-performing loans (bad loans) played a key role. The author constructs an economic model showing how bad loans combined with delayed bailout can lead to a persistent decline in economic activity by reducing bank lending. Quantitative analysis estimates the delayed bailout may have reduced Japan's annual GDP growth by up to 0.92 percentage points, accounting for much of its slow growth.
This document summarizes the 2009 Medicare & You handbook. It provides information about Medicare coverage, costs, and options. Key points include:
- Medicare covers hospital insurance (Part A), medical insurance (Part B), Medicare Advantage plans (Part C), and prescription drug coverage (Part D).
- Coverage and costs vary depending on the plan. Part A has a deductible and Part B has a premium and deductible. Advantage plans have premiums, deductibles, and other costs.
- Individuals have choices in how they receive Medicare benefits, including Original Medicare or Medicare Advantage plans. Plans must be joined during specific enrollment periods.
- The handbook provides information to help
Final ProjectThe major written assignment, a Health Policy Ana.docxvoversbyobersby
The document outlines the requirements for a major health policy analysis paper assignment. It provides details on the 9 sections that must be included: 1) problem statement, 2) background, 3) landscape identification, 4) alternatives section, 5) side-by-side tables of alternatives, 6) recommendations, 7) implementation strategy, 8) implementation planning, and 9) references. Students are asked to analyze a health-related problem and policy options for a state governor's office, researching online sources and the library. The paper should be 15-20 pages long.
Dobson DaVanzo Structural Changes Drive Health Care Spending SlowdownFedAmerHospital
If recent trends in health care spending growth continue, Medicare spending could be $2.6 trillion lower than 2008 projections through 2023, representing a 26% savings. Lower projections are due to structural changes in health care delivery that are unprecedented in scale and scope. These include risk-based payments, care coordination, and reduced benefits, which are causing behavioral changes among providers, payers and patients. If structural changes become further entrenched, they could produce long-term reductions in health care cost growth.
Intensive Care for Medicaid McQ Quarterly 2005Craig Tanio
This document summarizes a McKinsey report analyzing the unsustainable growth of Medicaid costs in the United States. It finds that by 2009, Medicaid will consume more than 75% of new state revenue in some states and 25-50% in many others. While opportunities exist to capture savings, actually doing so will require difficult decisions and creative leadership given political and structural challenges. Reform is needed to put Medicaid on a more stable long-term footing while still serving those in need.
Running head VERMONT HEALTH CARE REFORM2VERMONT HEALTH CARE.docxtoltonkendal
The Vermont Health Care Reform was established in 2011 after the state government passed a law allowing for a single-payer health care system. This created Green Mountain Care, a state-funded insurance pool providing universal coverage. However, it failed due to a lack of structured funding and political barriers. The complexity of establishing such a large reform demanded an effective funding structure and management system.
Health Care Reform Proposals Including the President’s PlanTom Daly
Michael Bertaut, Senior Healthcare Intelligence Analyst for Blue Cross Blue Shield of Louisiana provides an update on Healthcare Reform efforts including a review of the President's Plan released on February 22nd.
State Strategies (20 of grade)The purpose of this assignm.docxrafaelaj1
This document provides instructions for an assignment on state health policy reforms. Students must select a state innovation, describe the rationale behind it, how it was adopted, its funding structure, and available data on its impact. A 1-2 page memo summarizing these points is required. Examples given are Vermont's single-payer system and Massachusetts' reforms, which cannot be used. A rubric is also provided to evaluate the memos.
Breakfast Forum: The Continuing Crisis in Healthcare and its Impact on Texas ...BoyarMiller
This document summarizes a presentation given on April 1, 2010 about healthcare reform and its impact on Texas business. It discusses the continuing crisis in healthcare and its high costs. It provides details on the proposed healthcare reform bills, including funding sources and impacts. It also examines the specific impact on Texas, including the large number of uninsured residents, expected increased federal funding, and implications for providers, costs, and the state budget. The presentation was given by John Boettiger of Deloitte Financial Advisory Services.
The document discusses the implications of the Affordable Care Act on individuals, employers, and the healthcare industry. It finds that the Act will provide coverage to around 30 million uninsured Americans through Medicaid expansion and insurance subsidies. For individuals, there will be a penalty for not obtaining coverage starting in 2014. Employers with over 50 employees will face a penalty starting in 2015 if they do not provide affordable coverage. The healthcare industry will see both costs and revenues impacted, with insurers expected to gain many new customers but also facing new regulations, and hospitals losing some funding but gaining new insured patients. Overall the impacts are viewed as manageable for most employers and positive for the healthcare sector in the long run.
Assignment 1Public Administration – The Good, th.docxtrippettjettie
Assignment 1
Public Administration – The Good, the Bad, the Ugly
hhhhhhh
Modern Public Administration
Prof. hhhhh
Date: hhhhh
The White House Issue: Health reforms
The Health Care Reforms are the best obsession for the United States, Majorly most of the American citizens who were responsible for originating the improvement found it helpful. Back in the year 2011, a countrywide crackdown was conducted as a way to oppose the frauds that were becoming a health concern, and the federal administration recovered almost $ 4.1 billion. The Health Care Improvement for capturing the healthcare frauds and scams allowed President Obama’s policy to enhance on strict penalties like compensation and fines. By providing the United States citizens with Patient Protection as well as, ACA (Affordable Care Act) was the ultimate presidential success for President Barack Obama (.whitehouse., 2014).
The public policy
As most of the leaders decided to adopt a firm stand with the many important issues within the American State, the essential point was the definition of the improvement of the Health Care in the United States by President Barack Obama and when discussing the fitness and care reform a lot of issues are put on focus.
The public policies are categorized into four groups which are the regulatory policy, the distributive policy, the redistributive policy and lastly the constituent policy. Every issue in the White House is organized it the way it is related to any of the four types of public systems (NCBI, 2016). The financial regime faces most of the significant issues, and many may need to be in a position to determine the problems which are related to funding system because some of these issues affect some of the American citizens.
Distributive policy as mentioned above, it is a policy that focuses on supporting the selected issues; the strategy that is behind the distributive health care is the local understanding and having a flexible organizational design. The idea of distribution is quite broad as it classifies distributive policy action towards including all the public processes that are responsible for developing as well as providing equitable access to the resources. In regards to the health issues, this may have financial aid for assisting the excluded to have access to the healthcare. Also, across funding aid to assist in the inside operations of the health institutions such as the combination of threats which enhances the inclusion of reasonably inadequate health services. Also, the appointment systems facilitate the secondary concern for the needy to access health services (Mackintosh, 2013). It also reduces the shifts regarding the fitness care regime in processes that will be able to satisfy and offer the proper access to those who are deprived by supporting the distributive promises that the government has made and having full access to healthcare services. In this kind of shift, the significant disadvantage is ...
North Oakland Tea Party Presentation 8.23.12MattMcCord
This document discusses government-centered versus patient-centered healthcare and argues for a transition to a more patient-centered model. It summarizes some key provisions and costs of the Affordable Care Act and cites studies showing increased costs in Massachusetts. The document advocates for health savings accounts with high-deductible plans and direct primary care practices as an alternative that would give patients more control and reduce costs. It concludes that adopting these reforms could help citizens and the country by moving away from a government-dominated system and prioritizing patient-centered care instead.
The Affordable Care Act, also known as Obamacare, was established on March 23, 2010 under President Barack Obama. It aims to expand access to affordable health insurance by opening state-run health insurance exchanges. While intended to increase access to healthcare, Obamacare remains controversial with Democrats generally supporting it and Republicans opposing it. Over the next ten years, the program is expected to cost the government $1.1 trillion but reduce the federal deficit by $200 billion.
Health Reform in America: An Overview of the Patient Protection and Affordabl...Adam Dougherty
A lecture to the UC Davis School of Medicine community covering the basics of the health reform law passed in early 2010. Presented by Adam Dougherty, MPH, MS1
This document summarizes key points from a presentation on rural health issues and healthcare reform. It discusses potential government shutdowns if a budget is not passed, changes to Medicare and Medicaid under the Affordable Care Act, provisions already in effect, and new delivery models like accountable care organizations. Key uncertainties are noted, such as the impact of healthcare reform on rural providers and workforce shortages.
This document summarizes key points from a presentation by Grace-Marie Turner on the state of health reform in the US. The presentation discusses Americans' views on health reform, major provisions of the Affordable Care Act, independent studies that question whether the law will achieve its goals of reducing costs and expanding access, and concerns from physicians, businesses, and states. It predicts ongoing legal and political challenges to the healthcare law.
Running head MASSACHUSETTS’ HEALTHCARE REFORMS1MASSACHUSE.docxglendar3
Running head: MASSACHUSETTS’ HEALTHCARE REFORMS 1
MASSACHUSETTS’ HEALTHCARE REFORMS 3
Memo
To: Prof. Thomas Smith
From: Student- Jane Doe
Reference: Health Care Policy
Date: March 18, 2018
Subject: Massachusetts’ Healthcare Reform Act
Massachusetts’ Healthcare Reform Act
Rationale
Massachusetts State is among the states that have made a number of attempts aimed at reforming the state's healthcare system to make access to quality healthcare available for its residents. Recently in 2006, Massachusetts passed the Healthcare Reform Act, which was later, signed into law by former Governor Mitt Romney (Van der Wees et al., 2013). The rationale for this healthcare reform was to provide near-universal health insurance coverage for Massachusetts’ residents.
Adoption of the Reform
The Massachusetts Healthcare Reform Act was passed by the State legislators after years of negotiation between Mitt Romney and the legislators with a compromise reached in 2006 resulting in the enactment of the reform that was effectively signed into law by Romney on 12 April 206. The reform has made several changes to its healthcare system in a move aimed at achieving a near-universal healthcare coverage for the residents of the state. The first change was made to the state's Medicaid program that was broadened by providing a MassHealth waiver, extending health insurance coverage to children in low-income families with up to 300% of the federal poverty level (FPL) (Kaiser Family Foundation, 2012). Massachusetts created what is called Commonwealth Care, which provides the residents of the state with access to subsidized health insurance for eligible individuals with earnings below 300% of FPL. Under this new healthcare reform, individuals with income below 150% of FPL also have the option of selecting a plan without a monthly premium and low-cost sharing. However, eligible individuals with earnings falling between 150-300% PL are subsidized by the state using a sliding scale.
The Massachusetts Healthcare Reform Act also saw the state expand its Insurance Partnership Program by providing incentives and subsidies to the employers to give and workers to enroll in the state's employer-sponsored insurance. In this respect, Massachusetts State subsidized insurance costs for the workers in the state who would otherwise be eligible for programs subsidized by the government. However, small businesses are only eligible for up to $1,000 in support per qualified worker who falls below the 300% FPL (Van der Wees et al., 2013). Under the program, the state government pays the portion of qualified workers' premiums that is equal to what the employees would be expected to pay if employees were on a subsidized plan. Additionally, under this new healthcare reform, any employer in the state who fails to provide health insurance to its workers is expected to pay what is called a ‘fair share' assessment to the government of up to $295 per worker ever.
Running head MASSACHUSETTS’ HEALTHCARE REFORMS1MASSACHUSE.docxtodd581
Running head: MASSACHUSETTS’ HEALTHCARE REFORMS 1
MASSACHUSETTS’ HEALTHCARE REFORMS 3
Memo
To: Prof. Thomas Smith
From: Student- Jane Doe
Reference: Health Care Policy
Date: March 18, 2018
Subject: Massachusetts’ Healthcare Reform Act
Massachusetts’ Healthcare Reform Act
Rationale
Massachusetts State is among the states that have made a number of attempts aimed at reforming the state's healthcare system to make access to quality healthcare available for its residents. Recently in 2006, Massachusetts passed the Healthcare Reform Act, which was later, signed into law by former Governor Mitt Romney (Van der Wees et al., 2013). The rationale for this healthcare reform was to provide near-universal health insurance coverage for Massachusetts’ residents.
Adoption of the Reform
The Massachusetts Healthcare Reform Act was passed by the State legislators after years of negotiation between Mitt Romney and the legislators with a compromise reached in 2006 resulting in the enactment of the reform that was effectively signed into law by Romney on 12 April 206. The reform has made several changes to its healthcare system in a move aimed at achieving a near-universal healthcare coverage for the residents of the state. The first change was made to the state's Medicaid program that was broadened by providing a MassHealth waiver, extending health insurance coverage to children in low-income families with up to 300% of the federal poverty level (FPL) (Kaiser Family Foundation, 2012). Massachusetts created what is called Commonwealth Care, which provides the residents of the state with access to subsidized health insurance for eligible individuals with earnings below 300% of FPL. Under this new healthcare reform, individuals with income below 150% of FPL also have the option of selecting a plan without a monthly premium and low-cost sharing. However, eligible individuals with earnings falling between 150-300% PL are subsidized by the state using a sliding scale.
The Massachusetts Healthcare Reform Act also saw the state expand its Insurance Partnership Program by providing incentives and subsidies to the employers to give and workers to enroll in the state's employer-sponsored insurance. In this respect, Massachusetts State subsidized insurance costs for the workers in the state who would otherwise be eligible for programs subsidized by the government. However, small businesses are only eligible for up to $1,000 in support per qualified worker who falls below the 300% FPL (Van der Wees et al., 2013). Under the program, the state government pays the portion of qualified workers' premiums that is equal to what the employees would be expected to pay if employees were on a subsidized plan. Additionally, under this new healthcare reform, any employer in the state who fails to provide health insurance to its workers is expected to pay what is called a ‘fair share' assessment to the government of up to $295 per worker ever.
The document summarizes the Affordable Care Act and identifies some of its flaws and deficiencies. It discusses two main goals of the ACA - to increase the number of insured individuals while reducing overall healthcare costs. However, it notes the ACA has yet to achieve these goals. One deficiency is that individuals who remain uninsured face a penalty fee, which does not actually encourage accessing healthcare. Another issue is the "coverage gap" where many remain uninsured. The document proposes solutions like a state-run program to cover those in the gap and bundled payments to replace fee-for-service. It argues more reform is still needed to control rising costs while expanding access.
The State of Public Finances: A Cross-Country Fiscal MonitorPeter Ho
The global fiscal response to the crisis has been sizable but implementation has been uneven. Among G-20 countries, fiscal deficits are projected to increase by 5.5% of GDP in both 2009 and 2010 due to discretionary stimulus measures, automatic stabilizers, and falling revenues. Tax cuts have been implemented more quickly than spending measures. While a comprehensive assessment is difficult due to limited reporting, signs indicate the pace of stimulus spending has accelerated recently in some countries like the US. Overall, fiscal expansion has helped counter the economic downturn but medium-term fiscal strategies are still lacking in many countries.
The global economy is stabilizing after an unprecedented recession, helped by unprecedented policy support. However, the recession is not over and the recovery is expected to be sluggish. While growth is projected to be higher in 2010 than previously expected, the advanced economies are not expected to show sustained growth until the second half of 2010. Financial conditions have improved due to government intervention, but financial systems remain impaired and government support will gradually diminish.
How Did Economist Get It So Wrong Paul KrugmanPeter Ho
This document summarizes how mainstream economists failed to predict or prevent the 2008 financial crisis, despite believing they had resolved internal disputes and "solved" the problem of preventing depressions. It argues that economists mistook theoretical, mathematically elegant models of perfect markets for reality, ignoring limitations of human rationality and market imperfections that can cause crashes. It traces how mainstream economics shifted from Keynesian support for government intervention to stabilize economies to a neoclassical faith in free markets, with devastating consequences in the crisis.
1) The US recovery in the 1930s was rapid until 1937, when unemployment surged again due to a switch to contractionary fiscal and monetary policy that prolonged the Depression.
2) In 1937, fiscal stimulus from veterans bonuses and Social Security taxes disappeared, reducing the deficit by 2.5% of GDP. Additionally, the Federal Reserve doubled bank reserve requirements, unintentionally causing banks to reduce lending and precipitating recession.
3) The author argues that policymakers today must learn from 1937 and resist prematurely withdrawing stimulus until the economy reaches full employment to avoid derailing the recovery.
The document provides an overview and analysis of China's economic developments in the first half of 2009. It discusses three main points:
1) While China's economy has continued to feel the effects of the global crisis, very expansionary fiscal and monetary policies have supported growth. Government investment has soared while market investment has lagged. Consumption has held up well.
2) Exports remain very weak but imports have recovered as stimulus has boosted demand for raw materials. GDP growth was a respectable 6% in the first quarter.
3) Downward pressure on inflation has continued as falling raw material prices drag down prices, but overcapacity is squeezing industry profits. Growth is projected to remain around 7%
This paper introduces an imperfectly competitive banking sector into a DSGE model to study the role of credit supply factors in business cycle fluctuations in the euro area. Banks issue loans to households and firms, obtain funding via deposits, and accumulate capital from retained earnings. Margins on loans depend on bank capital ratios and interest rate stickiness. Estimating the model with euro area data from 1999-2008, the paper finds that:
1) Shocks originating in the banking sector explain most of the output fall in 2008, while macroeconomic shocks played a smaller role.
2) An unexpected reduction in bank capital can significantly impact the real economy, especially investment.
3) Financial frictions amplify monetary policy effects,
This document summarizes a research paper that develops a dynamic stochastic general equilibrium (DSGE) model to explain how monetary policy affects risk in financial markets and the macroeconomy. The key feature of the model is that asset and goods markets are segmented because it is costly for households to transfer funds between the markets. The model generates endogenous movements in risk as the fraction of households that rebalance their portfolios varies over time in response to real and monetary shocks. Simulation results indicate the model can account for evidence that monetary policy easing reduces equity premiums and helps explain the response of stock prices to monetary shocks.
This document summarizes a study that estimates a dynamic stochastic general equilibrium (DSGE) model to quantify the role of financial frictions, known as the financial accelerator mechanism, in U.S. business cycle fluctuations from 1973 to 2008. The model incorporates a high-information content credit spread index to identify the financial accelerator parameters and measure the impact of financial shocks on the real economy. Estimation results identify an operative financial accelerator, where increases in external financing costs significantly reduce investment and output. Financial disturbances accounted for significant portions of investment and output declines during economic downturns, particularly in the 1970s.
This paper integrates agency costs into a standard Dynamic New Keynesian model in a transparent way. Agency costs are modeled as a collateral constraint on entrepreneurial hiring of labor based on net worth. Three key results are:
1) Agency costs act as endogenous markup shocks in the Phillips curve.
2) The model welfare function includes a measure of credit market tightness interpreted as a risk premium.
3) Optimal monetary policy can be characterized as an inflation targeting rule, but it may optimally deviate from strict inflation stabilization in response to financial shocks.
Lessons from the Great Depression for Economic Recovery in 2009Peter Ho
This document discusses lessons from the Great Depression that may help guide economic recovery efforts in 2009. It notes that while the current recession is severe, it is less severe than the Great Depression. It outlines parallels between the two events, including their origins in financial crises and asset price declines. The document discusses four key lessons from the 1930s: 1) small fiscal stimulus had limited effects so a large stimulus is needed; 2) monetary policy can help even at low rates by affecting expectations; 3) stimulus should not be withdrawn too soon; and 4) financial stability and real recovery go hand in hand. The goal is to apply these lessons to end the current recession.
Lessons of the Financial Crisis for Future Regulation of Financial InstitutionsPeter Ho
The document summarizes lessons learned from the ongoing financial crisis for future regulation of financial institutions and markets. Key points include:
- The crisis exposed inadequacies in regulation, supervision, and risk management that failed to prevent excessive risk-taking. Reform is needed to address these issues.
- Priorities for reform include expanding regulation to new entities, addressing procyclicality of capital requirements, improving information sharing, resolving cross-border regulatory issues, and strengthening central bank liquidity management.
- International bodies like the FSF and G20 working groups are examining these issues and developing policy recommendations, but more work is still needed to implement reforms.
The Size of the Fiscal Expansion: An Analysis for the Largest CountriesPeter Ho
The document analyzes the size of fiscal stimulus packages implemented by major countries in response to the 2008 financial crisis. It finds that the size of packages varied significantly, ranging from 4.8% of GDP for the US to 0.5% for India. This variation is explained by differences in the need for stimulus due to factors like automatic stabilizers and output gaps, as well as differences in available fiscal space constrained by public debt levels and financial sector support needs. While stimulus efforts will provide important support to growth, the outlook remains weak and downside risks remain, so some argue additional fiscal action may be needed if properly designed to not permanently increase deficits.
This document summarizes initial lessons from the financial crisis in three areas: regulation, macroeconomic policy, and the global financial system. Key failures included fragmented regulation that allowed regulatory arbitrage, a lack of coordination between macro and financial stability policies, and an inability within the global system to identify vulnerabilities. Lessons indicate regulation needs broader oversight of all systemically important financial activities, macro policies should consider financial stability risks, and greater international cooperation is required.
STOCKTAKING OF THE G-20 RESPONSES TO THE GLOBAL BANKING CRISISPeter Ho
The document provides a preliminary assessment of policy responses by G-20 countries to address the global banking crisis from September 2008 to February 2009. It finds that initial responses were reactive and aimed at containment through measures like debt guarantees and liquidity support. Key limitations identified include inadequate creditor protection if economic conditions worsen, ad hoc capital injections, and a lack of frameworks for asset management. Going forward, the document recommends a more comprehensive and coordinated international strategy across four elements: coordination of restructuring policies, cooperation on toxic asset valuation and disposal, financial institution inspections, and frameworks for public ownership of banks.
The document provides an overview and analysis of the global economic outlook by the IMF staff. It finds that:
1) Global economic activity has fallen sharply, with advanced economies experiencing their worst declines since World War 2.
2) The IMF forecasts that the global economy will contract by 0.5-1% in 2009 on average before a gradual recovery in 2010.
3) Turning the global economy around depends critically on concerted policy actions to stabilize financial conditions and support demand through fiscal and monetary policies.
This document provides a summary of new and revised IFRS standards and interpretations that will become effective in 2009. Key changes include revisions to IAS 1 regarding financial statement presentation, IAS 27 and IFRS 3 introducing a single consolidation model, and IFRS 8 bringing segment reporting in line with US GAAP. Other standards are also amended relating to borrowing costs, business combinations, financial instruments, and share-based payments. The document outlines the implementation dates and provides high-level details of the changes required by each new or revised standard.
The document discusses the bankruptcy discharge process. It explains that:
1) A bankruptcy discharge releases debtors from personal liability for certain debts and prohibits creditors from collecting on those debts. However, valid liens remain enforceable.
2) The timing of discharge varies by chapter, but generally occurs 4 months after filing for chapter 7 and after completing all payments under chapter 12 or 13 plans, which usually takes 3-5 years.
3) Not all debts are discharged - there are several categories of debt that are exempt from discharge for public policy reasons, such as certain taxes, debts from fraud or willful/malicious behavior, and student loans. Creditors must object to the discharge of other specified debts.
This document provides an overview of the oil market in March 2009. It discusses the relative stability of crude oil prices despite continued economic uncertainties and downward revisions to oil demand forecasts. Global oil demand is expected to decline by 1.0 mb/d in 2009, with OECD seeing a decline of 1.3 mb/d. Non-OPEC supply is projected to increase by 0.4 mb/d in 2009. Required OPEC crude is projected to decrease by 1.8 mb/d in 2009 compared to 2008. The document also discusses movements in the OPEC Reference Basket price in February 2009 and issues to be considered at the upcoming OPEC conference.
The 1990’s financial crises in Nordic countriesPeter Ho
The 1990s financial crises in the Nordic countries impacted Finland, Norway, and Sweden. All three countries experienced rapid growth and lending in the 1980s that led to overheating and current account deficits. This was followed by deep recessions in the early 1990s as asset and housing prices collapsed, unemployment rose, and banks faced huge losses. Finland's crisis was the most severe, with over 10% cumulative GDP decline. Public authorities had to provide significant support to stabilize the banking systems. The crises highlighted the risks of financial deregulation and overheating from excessive lending and asset price booms.
Why the U.S. Treasury Began Auctioning Treasury Bill in 1929Peter Ho
In 1929, the U.S. Treasury introduced Treasury bills to address flaws in its financing operations from the 1920s. Specifically, Treasury debt offerings were chronically oversubscribed when sold at fixed prices, and the Treasury had to borrow in advance of its needs between its quarterly debt sales and tax payment dates. By auctioning Treasury bills regularly and on an as-needed basis, the Treasury was able to better manage its cash flows and meet its financing needs in a more flexible manner. The introduction of Treasury bills allowed the Treasury to mitigate defects in the existing system while maintaining the overall structure of its operations.
Here is Gabe Whitley's response to my defamation lawsuit for him calling me a rapist and perjurer in court documents.
You have to read it to believe it, but after you read it, you won't believe it. And I included eight examples of defamatory statements/
Acolyte Episodes review (TV series) The Acolyte. Learn about the influence of the program on the Star Wars world, as well as new characters and story twists.
Essential Tools for Modern PR Business .pptxPragencyuk
Discover the essential tools and strategies for modern PR business success. Learn how to craft compelling news releases, leverage press release sites and news wires, stay updated with PR news, and integrate effective PR practices to enhance your brand's visibility and credibility. Elevate your PR efforts with our comprehensive guide.
El Puerto de Algeciras continúa un año más como el más eficiente del continente europeo y vuelve a situarse en el “top ten” mundial, según el informe The Container Port Performance Index 2023 (CPPI), elaborado por el Banco Mundial y la consultora S&P Global.
El informe CPPI utiliza dos enfoques metodológicos diferentes para calcular la clasificación del índice: uno administrativo o técnico y otro estadístico, basado en análisis factorial (FA). Según los autores, esta dualidad pretende asegurar una clasificación que refleje con precisión el rendimiento real del puerto, a la vez que sea estadísticamente sólida. En esta edición del informe CPPI 2023, se han empleado los mismos enfoques metodológicos y se ha aplicado un método de agregación de clasificaciones para combinar los resultados de ambos enfoques y obtener una clasificación agregada.
An astonishing, first-of-its-kind, report by the NYT assessing damage in Ukraine. Even if the war ends tomorrow, in many places there will be nothing to go back to.
1. UNITED STATES HOUSE OF REPRESENTATIVES
COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM
MAJORITY STAFF
MARCH 2008
THE ADMINISTRATION’S MEDICAID
REGULATIONS: STATE-BY-STATE IMPACTS
PREPARED FOR
CHAIRMAN HENRY A. WAXMAN
2. TABLE OF CONTENTS
EXECUTIVE SUMMARY ........................................................ 1
I. BACKGROUND .............................................................. 3
II. COMMITTEE’S INVESTIGATION ..................................... 5
III. FINDINGS ....................................................................... 6
A. Cost Limits for Public Providers (CMS 2258-FC)...................................9
B. Graduate Medical Education (GME) (CMS 2279-P).........................10
C. Outpatient Hospital Services (CMS 2213-P) ......................................11
D. Provider Taxes (CMS 2275-P) ..............................................................11
E. Rehabilitative Services (CMS 2261-P) ................................................12
F. School Administration and Transportation Services (CMS 2287-P) .12
G. Case Management Services (CMS 2237-IFC) ..................................13
IV. CONCLUSION.............................................................. 14
3. EXECUTIVE SUMMARY
On November 1, 2007, the Committee on Oversight and Government Reform held a
hearing on regulations issued by the Centers for Medicare & Medicaid Services (CMS)
that would make major, wide-ranging changes in federal Medicaid policy. In general, the
seven regulations at issue represent unilateral actions by CMS neither directed nor
authorized by Congress. The Committee heard testimony from the principal author of the
regulations, Dennis Smith, the Director of the Centers for Medicaid and State Operations
within CMS. According to the Administration, the regulations would reduce federal
Medicaid payments to states by a total of more than $15 billion over the next five years.
These estimates, like those issued at the time the regulations were published, are national
in scope. They do not enable members of Congress or the public to assess the effect of
the regulation on their own states. In a program like Medicaid, which is operated by the
states on a day-to-day basis and is famous for its variation from state to state, the lack of
state-specific estimates represents a major failure of transparency. Mr. Smith, who has
lead responsibility for administering the Medicaid program at the federal level, did not
present any estimates of the state-specific impact of the regulations, either at the hearing
or in response to subsequent Committee requests.
On January 16, 2008, the Committee wrote to each state Medicaid Director requesting a
state-specific analysis of the impact of each of the regulations. The Committee received
responses from 43 states and the District of Columbia, accounting for approximately 95%
of total Medicaid spending. This report analyzes these responses. It is the first state-
specific assessment of the impact of the CMS regulations.
The report finds that the state estimates of the fiscal impacts of the regulatory changes are
significantly higher than the $15 billion impact projected by the Administration.
According to the states who responded to the Committee, the regulations would reduce
federal payments to them by $49.7 billion over the next five years, more than three times
the Administration’s estimate. In the case of one regulation, the state estimates of lost
federal funds are more than ten times the Administration’s estimate.
The report also finds:
• The combined effect of the reductions in federal funds from all
seven regulations represents a major fiscal blow for many states.
Estimates of the loss of federal funds from all of the regulations range from $7.4
million over five years in Ohio to $10.8 billion over five years in California. The
Missouri Medicaid Director explained the cumulative impact: “The combined
loss of federal funding for these four regulations for the next five state fiscal years
is an average of over $250 million annually. The effects are even more severe
when coupled with the corresponding loss of state funding which would result in
a total loss of an average of $400 million annually. Such a loss of funding would
cause significant cash flow shortages, causing a financial strain on Missouri
hospitals which service almost 850,000 MO HealthNet participants plus the
1 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
4. uninsured. This financial strain, in turn, will result in an adverse impact on the
health and welfare of MO HealthNet participants and uninsured individuals in
need of medical treatment.”
• The regulations will reduce federal spending by shifting costs, not
through greater efficiencies. The Oregon Medicaid Director wrote: “Taken
together, the overall effect will reduce federal Medicaid spending within Oregon
by approximately $877 million over the next five years. Most of these costs will
simply be shifted on the state and local government, at a time when Oregon has
less capacity to absorb added costs given the economic slowdown, reduction of
timber revenue, weakening fiscal conditions, increased caseloads, and an increase
in client demand.”
• The regulations will disrupt existing systems of care for fragile
populations. The Minnesota Medicaid Director reported: “Implementation of
these rules will limit state flexibility to implement or maintain effective and
innovative models of care, require us to fragment integrated care programs, and
significantly increase the administrative complexity and therefore cost of our
Medicaid program. In issuing the rules, CMS cites the need to protect the fiscal
integrity of the federal commitment to Medicaid. Ironically, many of the
agency’s proposals will actually result in special needs populations receiving less
effective models of care at increased state and federal cost.”
• The regulations threaten the financial stability of the hospitals,
emergency rooms, and clinics that treat Americans without health
insurance. The California Medicaid Director writes that these regulations
“have the potential of reducing federal reimbursements to California by several
billion dollars annually. … The reductions in federal funding are likely to lead to
destabilization of an already fragile health care, safety-net system in California,
which bears a heavy burden in rendering needed health care services to Medicaid
beneficiaries and the uninsured.”
• The regulations will impose significant administrative burdens and
costs on state Medicaid programs. The Virginia Medicaid Director stated:
“One cost that is not quantified is the administrative burden on the State Medicaid
agency and many providers to implement these regulations. These costs may be
worthwhile if they represent an improvement in policy. In some cases, however,
much of the policy embedded in the regulation is dubious or pointless. In other
cases, the regulations represent a reversal of long-standing policy, such as
Medicaid reimbursement for graduate medical education or school administrative
costs. The Department of Medical Assistance Services would also expect
unforeseen consequences.”
• The impact of the regulations extends beyond Medicaid
beneficiaries. Some states reported that the number and scope of the policy
changes in the regulations would have significant effects beyond their Medicaid
2 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
5. programs. For example, the Georgia Medicaid Director wrote: “The financial
impact to the state of Georgia is significant, estimated at $2.6 billion through June
30, 2012. While the short term impact in Georgia most directly impacts the
state’s ability to finance Medicaid provider reimbursement, I am concerned that
the long-term impact will result in decreased access to care, not only for our
Medicaid members, but for all citizens.”
• The regulations do not have the support of the State Medicaid
Directors. The Texas Medicaid Director, as just one example of the State
Medicaid Director’s lack of support, responded: “Texas could lose $3.4 billion in
federal Medicaid funds during fiscal years 2008-2012 as a result of these
regulations. … In Texas, Medicaid accounts for 26 percent of the state’s total
budget, provides health care for one out of every three children, pays for more
than half of all births, and covers two-thirds of all nursing home residents. We
share CMS’s goal of achieving greater accountability in the Medicaid budget;
however, we urge a different approach that more fully weighs the programmatic
as well as the fiscal implications of making changes to the program. Further,
states and hospitals must be given enough time to make the system changes
necessary to support greater accountability.”
The methodologies used by the states in preparing their estimates for the Committee
differ from state to state and from the methodology used by CMS. Nonetheless, the large
discrepancy between the state estimates and the CMS estimates is evidence that the
regulations are likely to have a much larger fiscal and programmatic impact on state
Medicaid programs and state budgets than federal policymakers realize.
I. BACKGROUND
Medicaid is a federal-state program that purchases a broad range of health and long-term
care services from hundreds of thousands of providers on behalf of 60 million low-
income Americans. States administer the Medicaid program on a day-to-day basis within
broad federal requirements. The federal government matches the cost to states of
purchasing covered services on behalf of eligible individuals. The federal matching rate
varies from a low of 50% to a high of 76%, depending on the state’s per capita income.
In FY 2008, the federal government is projected to spend $207 billion on Medicaid,
making Medicaid by far the largest federal grant program to the states. Under Office of
Management and Budget (OMB) projections, Medicaid this year will account for 46% of
all federal grants in aid, dwarfing programs like federal aid for education and social
services ($57 billion) and federal aid for highways ($38 billion). As a consequence,
when the federal government changes Medicaid policy by restricting the state costs that it
will match, there is an impact not only on state Medicaid programs but on state budgets
generally. 1
1 Office of Management and Budget, Analytical Perspectives: Budget of the U.S. Government,
Fiscal Year 2009, Table 8-4 (Feb. 2008).
3 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
6. In 2003, the Government Accountability Office (GAO) designated Medicaid as a
program at high risk of mismanagement, waste, and abuse. 2 This designation was based
in part on a GAO finding that some states had used “creative financing arrangements” to
increase the effective federal matching rate while reducing the state’s own contribution to
program costs. Between August 2003 and August 2006, CMS took administrative
actions to end inappropriate state financing arrangements in 29 states. 3 In 2005, GAO
also examined state use of consultants on contingency fee arrangements to maximize
federal Medicaid revenues and made a number of recommendations to CMS designed to
better monitor state use of contingency fee consultants in order to reduce inappropriate
claims for federal matching funds. GAO also recommended that CMS establish or clarify
policies relating to targeted case management, rehabilitation services, supplemental
payment arrangements, and administrative costs. The purpose of this recommendation
was to “strengthen CMS’ overall financial management of state Medicaid activities.” 4
GAO did not recommend that CMS make major changes in federal Medicaid policy such
as discontinuing federal matching funds for graduate medical education, discontinuing
federal payments for outreach and enrollment activities by school employees, or
discontinuing federal payments for therapeutic foster care services. 5
During 2007, CMS issued seven regulations that would make major, wide-ranging
changes in federal Medicaid policy. (For a brief description of each regulation and its
current status, see Appendix B.) Two of these regulations would reduce Medicaid
reimbursements for services furnished by public hospitals and teaching hospitals.
Another would restrict how states can raise revenues from the health care sector of their
economies in order to fund their share of Medicaid. The remaining regulations would
narrow the scope of allowable Medicaid coverage for outpatient hospital services,
rehabilitation services, school-based administrative and transportation services, and case
management services. With a few exceptions, these regulations are unilateral actions by
CMS, not policy changes directed by Congress. 6 As the Kentucky Medicaid Director
noted:
2 U.S. Government Accountability Office, Major Management Challenges and Program Risks:
Department of Health and Human Services (Jan. 2003) (GAO/03-101).
3 Statement of Dr. Marjorie Kanof before the Committee on Oversight and Government Reform,
Medicaid Financing: Long-Standing Concerns about Inappropriate State Arrangements Support
Need for Improved Federal Oversight (Nov. 1, 2007) (GAO/08-255T).
4 U.S. Government Accountability Office, Medicaid Financing: States’ Use of Contingency-Fee
Consultants to Maximize Federal Reimbursements Highlights Need for Improved Federal Oversight,
46 (June 28, 2005) (GAO/05-748).
5 House Committee on Oversight and Government Reform, Testimony of Dr. Marjorie Kanof,
Hearing on the Administration’s Regulatory Actions on Medicaid: The Effects on Patients, Doctors,
Hospitals, and States, 110th Cong., 100 (Nov. 1, 2007).
6 Even in the two instances in which the regulations are ostensibly related to Congressional action,
the regulations go far beyond any legislative change. These two instances concern provider taxes
and targeted case management. In the first case, Congress made relatively small changes
enacting a temporary reduction in a rate and a definitional change. (Tax Relief and Health Care
Act of 2006, P.L. 109-432, Section 403; Deficit Reduction Act of 2005, P.L. 109-171, Section 6051) The
new regulation, however, makes sweeping changes in current provider tax regulations that have
nothing to do with these changes. In the second case, Congress altered the statutory definition of
“case management services.” (Deficit Reduction Act of 2005, P.L. 109-171, Section 6052) The new
regulation makes substantial changes not authorized by that provision.
4 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
7. These regulations represent a continuation of CMS’s efforts over the last
four to five years to continually eliminate and scale back needed services
for Kentucky’s Medicaid recipients which had previously been
allowable under longstanding federal regulations. 7
According to the Office of Management and Budget, these regulations would reduce
federal Medicaid spending by a total of $15 billion over the five year period FY 2009 -
FY 2013. 8 These estimated reductions in federal Medicaid spending are not the result of
a drop in the need for the services or a decline in the cost of delivering the services.
Instead, these reductions in federal spending would occur because the federal government
will no longer match the cost of services or administrative activities for which it is
currently making matching payments. State Medicaid programs would then face the
choice of no longer paying for the service or activity, or continuing to pay for the service
or activity entirely with state funds. In those instances where the state decides to
continue to pay for the service or activity, the result of the change in regulatory policy is
a shift of costs from the federal government to the states. 9
II. COMMITTEE’S INVESTIGATION
The number and scope of the policy changes involved, and the fiscal impact of those
changes on the states, led the Committee on Oversight and Government Reform to
initiate an investigation.
On November 1, 2007, the Committee held a hearing on the Medicaid regulations that
had been published as of that date. The Committee heard testimony from Dennis Smith,
the official within CMS who is the primary author of the regulations, as well as from a
State Medicaid Director, the Government Accountability Office, an emergency care
physician, a teaching hospital physician, a public hospital administrator, a school nurse,
the manager of a child welfare program, and a former recipient of rehabilitative
services. 10
At the hearing, Mr. Smith testified: “State governments have a great deal of
programmatic flexibility within which to tailor their Medicaid programs to their unique
political, budgetary, and economic environments. Accordingly, there is variation among
the States in eligibility, services, and reimbursement rates to providers and health
7 Letter from Elizabeth A. Johnson, Commissioner, Cabinet for Health and Family Services
Department for Medicaid Services, to Rep. Henry A. Waxman, Chairman, House Committee on
Oversight and Government Reform (Feb. 18, 2008).
8 Office of Management and Budget, Analytical Perspectives: Budget of the U.S. Government,
Fiscal Year 2009, Table 25-6 (Feb. 2008). The five-year OMB estimates for each regulation are set
forth in Appendix B.
9 Kaiser Commission on Medicaid and the Uninsured, Medicaid: Overview and Impact of New
Regulations (Jan. 2008).
10 House Committee on Oversight and Government Reform, Hearing on the Administration’s
Regulatory Actions on Medicaid: The Effects on Patients, Doctors, Hospitals, and States, 110th
Cong. (Nov. 1, 2007).
5 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
8. plans.” 11 Because of this variation among state programs, it is highly likely that each
regulation would have differing impacts on different states — differences that federal and
state policymakers alike would want to understand. In order for Medicaid policy changes
to be truly transparent, a state-by-state impact analysis of regulatory proposals is
essential.
Mr. Smith described his agency’s regulatory proposals and the reductions in federal
payments to states that these proposals would yield nationwide, but he did not provide the
Committee with state-specific information. On November 26, 2007, the Committee
requested state-specific analyses of the fiscal and beneficiary impact of each regulation.
On February 22, 2008, Mr. Smith responded:
With respect to your second request concerning state-specific impact
analyses, I regret that we are unable to develop and report this
information. While we share your interest in having state specific
impacts, it is not possible at this time to generate accurate assessments due
to a variety of deficiencies in data collection including variation in state
reporting, changes in state funding practices, current available data
sources, information systems, and resource levels. … While we have taken
a number of steps to improve our data collection systems, we continue to
be concerned that state-by-state impacts would not be reliable. 12
III. FINDINGS
On January 16, 2008, the Committee wrote to the Medicaid Directors of each state and
the District of Columbia asking for an analysis of the impact on their state of each of the
seven Medicaid regulations listed in Appendix B. Responses were requested by February
15, 2008. As of February 29, 2008, the Committee had received written responses from
Medicaid Directors of 43 states and the District of Columbia. These jurisdictions account
for approximately 95% of total Medicaid spending and represent all regions of the
country: Northeast, South, Midwest, and West. This staff report presents the findings
from these responses. The seven states that did not respond by February 29 were
Alabama, Arkansas, Mississippi, Nebraska, Vermont, West Virginia, and Wyoming.
As shown in Table 1, the impact of each regulation varied from state to state. For
example, ten of the responding states indicated that the regulation limiting payments to
public providers would have no impact (indicated by “None”). Of the remaining 34
responding states (including the District of Columbia), 22 were able to quantify the fiscal
impact, while 12 did not specify what the fiscal impact would be (indicated by “NS,” or
not specified).
In those cases where a state did not specify the fiscal impact of a regulation — i.e., NS —
the reason generally given was lack of clarity in the regulatory purpose or text. For
Id.
11
Letter from Dennis G. Smith, Director, Center for Medicaid and State Operations, to Rep. Henry A.
12
Waxman, Chairman, House Committee on Oversight and Government Reform (Feb. 22, 2008).
6 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
9. example, the Delaware Medicaid Director, in describing the impact of targeted case
management services rule, wrote: “Given the uncertainty regarding the scope of the rule
and the absence of clear guidance from CMS, it is extremely difficult to develop accurate
fiscal impact estimates. However, the apparent intent of CMS to apply these
requirements broadly raises concerns that a significant portion of our Medicaid
population would be seriously and immediately impacted.”
In those cases where a state did specify the fiscal impact of a regulation, the estimate
refers only to federal Medicaid matching funds that would be lost to the state. 13 The
estimate does not include additional costs that a state would expect to incur in order to
comply with a regulation — costs that could result in additional federal spending. These
costs could be administrative, as illustrated by the Ohio Medicaid Director’s comment
that the case management regulation “will result in additional costs as well due to
increased staffing needs, increased payments for case management activities, decreased
controls, the need to restructure eligibility/service authorization and other gate keeping
systems and significant changes to information technology systems to accommodate the
newly required fifteen minute billing unit.”
These costs could also take the form of more expensive services. This is illustrated by
the following comment from the Louisiana Medicaid Director regarding the rehabilitative
services regulation: “As of February 6, 2008, 2,599 children are receiving MHR services
and we would estimate as many as 90% would no longer qualify for MHR under a strict
interpretation of the proposed rule. We cannot quantify the fiscal impact, since we don’t
know how many of these children would end up in inpatient psychiatric hospitals
($538.80 per day), Office of Youth Development (OYD) detention facilities ($415.48 per
day) or Office of Community Services (OCS) congregate care ($138-$169 per day).
Therefore, the fiscal impact would be significant and negative, since on average, we
currently expend only $12.73 per day or $381.90 per member per month in the MHR
program.” The estimates set forth in Table 1 do not include such additional state (and
federal) costs.
13In some cases, states supplied a range of estimates. For example, the Kentucky Medicaid
director indicated that the GME regulation “would eliminate an estimated $24 to $27 million in
federal funds per year over the next 5 years…” The table reflects the lower bound of the estimate.
7 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
11. The regulations estimated to have the greatest impact, measured in terms of number of
responding states affected, were those relating to case management (only one state
reported that the regulation would have no impact); graduate medical education (two
states reported no impact); rehabilitative services (three states reported no impact); and
school administrative and transportation (three states reported no impact). In the case of
each of the remaining regulations, a majority of the responding states reported an impact.
The responding states estimated that the regulations as a whole would result in a loss of
$49.7 billion in federal Medicaid funds over the next five years. The regulation that the
responding states estimated would cause the greatest loss in federal funds is the cost limit
on public providers ($21.1 billion over five years), followed by GME ($9.8 billion),
rehabilitative services ($5.2 billion), provider taxes ($5.1 billion), school administration
and transportation ($3.2 billion), case management ($3.1 billion), and outpatient hospital
services ($2.1 billion).
Among the responding states, the state projecting the highest loss of federal funds over
the next five years from all seven regulations was California ($10.8 billion), followed by
New York ($7.3 billion), Michigan ($3.9 billion), Texas ($3.4 billion), North Carolina
($2.7 billion), Georgia ($2.6 billion), and Illinois ($2.5 billion). In short, these seven
states alone estimate a five-year fiscal impact of $33.2 billion — twice as large as that
estimated by the Office of Management and Budget (OMB).
These estimates should be viewed with caution, for several reasons. First, not all states
responded. Second, the states that did respond may have used different estimation
methods, which could lead to differences in five-year estimates. For example, state fiscal
years do not generally track federal fiscal years. Third, some of the states that provided
estimates sometimes qualified those estimates by indicating that they had not had an
opportunity to conduct a full analysis, so that their estimate might understate the actual
impact. Finally, as noted above, in many cases states indicated that one or more
regulations would have an impact but were not able to specify that impact. The fact that
a regulation is drafted so vaguely that many states are unable to specify the loss in federal
funds that would result does not mean that the regulation will not cost them federal funds.
The remainder of this report summarizes the findings specific to each regulation.
A. Cost Limits for Public Providers (CMS 2258-FC)
As shown in Appendix C, ten states indicated that this regulation would have no impact
on them. 21 states and the District of Columbia provided estimates of the amount of
federal funds they would lose as the result of this regulation. 12 states reported that this
regulation would have a fiscal impact but were not able to quantify that impact. The loss
in federal funds over five years, as estimated by the states, totals $21.1 billion. The OMB
estimate of the reduction in federal funds over the five years FY 2009 - FY 2013 is $5.7
billion. 14
14 Office of Management and Budget, Analytical Perspectives: Budget of the U.S. Government,
Fiscal Year 2009, Table 25-6 (Feb. 2008).
9 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
12. The Illinois Medicaid Director explained the implications of this rule for his state:
We estimate the reduction in [federal Medicaid matching funds] to Illinois
over the next five years to be over $1.3 billion. The vast majority of this
reduction will be due to reduced payments to public hospitals. As the
providers of last resort, public hospitals play a vital role in serving not
only Medicaid beneficiaries, but also the uninsured. Because Illinois has,
relative to the size of the State, a low ($202.5 million) federal allocation
for disproportionate share hospital adjustment (DSH) payments, we have
used Medicaid payments in excess of Medicaid costs to maintain access to
needed care by uninsured individuals who are not Medicaid-eligible … .
Enforcement of the rule will create a serious funding problem for
relatively low DSH states, like Illinois, that have relied on basic Medicaid
reimbursement to make up the shortcomings in their DSH allotment.
B. Graduate Medical Education (GME) (CMS 2279-P)
Appendix D summarizes the state responses relating to the regulation that would prohibit
federal Medicaid funding for the costs of medical interns and residents. Only two states
indicated that the regulation would have no impact. Most of the remaining states (36,
including the District of Columbia) provided estimates of the loss of federal funds over
five years; these estimates total $9.8 billion. The OMB estimate of the reduction in
federal funds over the five years FY 2009 – FY 2013 is $1.8 billion. 15
Colorado provides one example of the impact of this regulation:
This proposed regulation would … eliminate supplemental funding to
Colorado’s teaching hospitals. These hospitals provide critical physician
services to Medicaid and low-income populations. Approximately 1,157
fellows and residents in training, in 14 sponsoring institutions around the
State, would be negatively impacted by the regulation. These fellows and
residents provide medical services to over 100,000 Medicaid and low-
income clients each year. The State’s teaching hospitals report that they
would not be able to continue their education programs at the current
levels without the federal Medicaid funding. The regulation is a Medicaid
policy change that is expected to result in loss of revenue of approximately
$12 million per year in Colorado. This would represent more than a 25%
decline in revenue to Colorado’s teaching programs and would force the
programs to reduce staff and stop serving Medicaid clients in their
outpatient clinics. As such, the regulation threatens the financial stability
of these teaching programs and the safety-net provider community.
15 Id.
10 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
13. C. Outpatient Hospital Services (CMS 2213-P)
As shown in Appendix E, 21 states and the District of Columbia report that this
regulation will have no impact on them. Another 18 states report that there may be a
financial impact but they are not able to quantify it. Four states, California, Illinois,
Louisiana, and Missouri, supplied estimates of federal funds that they would lose ($1.3
billion, $700 million, $19 million, and $37 million, respectively). CMS states in its
proposed rule that “[d]ue to the lack of available data, we cannot determine the fiscal
impact of the proposed rule.” 16
The implications of this regulation were described by the Nevada Medicaid director:
The more restricted definition of “outpatient services” may not only
reduce hospital revenues by limiting/eliminating reimbursable services
such as early, periodic screening, diagnosis and treatment for children;
dental services for children; physician emergency department services;
physical, occupational and speech therapies; outpatient clinical diagnostic
laboratory services; ambulance services; durable medical equipment; and
outpatient audiology services but create major access problems as well
(emphasis in original). CMS seems to be taking the unsupported position
that services no longer reimbursed through hospital outpatient departments
will be provided by and paid for through other parts of the Medicaid
program. In large swaths of rural Nevada, it is unclear that such services
are available anywhere but from small, “safety net” hospital outpatient
departments.
D. Provider Taxes (CMS 2275-P)
Appendix F summarizes the responses relating to the provider tax regulation. 15 states
indicated that the regulation would have no impact on them. 16 states, including the
District of Columbia, furnished estimates, while 13 states were not able to specify the
impact. The states that supplied estimates projected a total loss of $5.1 billion in federal
Medicaid matching funds from this regulation. The CMS estimate is $430 million over
the five-year period FY 2008 – FY 2012. 17
The Kansas Medicaid Director described the potential implications of this regulation:
The Kansas Medicaid Provider Tax is a relatively new program that began
in SFY2005 with CMS approval of the methodology. CMS conducted an
audit of the KS Provider Tax fund and payouts during SFY2007. Due to
the recent approval and review, the Kansas program is in compliance with
16 Centers for Medicare & Medicaid Services, Medicaid Program; Clarification of Outpatient Clinic
and Hospital Facility Services Definition and Upper Payment Limit, 72 Fed. Reg. 55164 (Sept. 28,
2007) (proposed rule).
17 Centers for Medicaid & Medicare Services, Medicaid Program; Health Care-Related Taxes, 73
Fed. Reg. 9697 (Feb. 22, 2008).
11 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
14. the current regulations. In regards to the proposed CMS rule, we do not
know how the clarifications may impact this program. However, it is clear
that loss of this program has the potential to severely restrict KS Medicaid
beneficiaries’ access to hospital and physician providers. KS would
anticipate a reduction of 25% in KS Medicaid claims payment rates due to
the loss of federal matching funds as well as an elimination of direct
access payments to hospital providers.
E. Rehabilitative Services (CMS 2261-P)
As shown in Appendix G, all but three of the responding states reported that this
regulation would have an impact. 23 states were not able to quantify the fiscal impact.
The 18 states that were able to do so estimate that, in total, the regulation would result in
a loss of $5.2 billion in federal Medicaid funds over the next five years. The OMB
estimate of the reduction in federal payments to states attributable to this regulation is
$2.7 billion over the five-year period FY2009 – FY2013. 18
The Utah Medicaid Director made the following observation about the impact of this
regulation on his state:
Public mental health providers have a significant share of seriously and
persistently mentally ill (SPMI) consumers for whom medication
management may be the primary, if the not exclusive rehabilitative service
modality. Through effective symptom management many such consumers
who previously spent years in State hospitals or cycled repeatedly through
acute inpatient settings have been able to maintain institutional
independence … . If the Medicaid rehabilitation rule is finalized as
proposed, there is concern that exclusive medication management services
could be interpreted as a maintenance or custodial benefit and could
therefore become vulnerable to a denial of coverage … . Such an outcome,
we predict, would result in higher rates of inpatient care and institutional
utilization, with untold costs to both consumer and system alike.
F. School Administration and Transportation Services (CMS 2287-
P)
Appendix H sets forth the state responses regarding the regulation denying federal
matching payments for school administration and transportation costs. Only three states
reported that this regulation would have no impact on them. 34 states, including the
District of Columbia, provided estimates of the fiscal impact of this regulation, while
seven states did not specify the impact. In total, the states supplying estimates projected
a loss of federal funds of $3.2 billion over the next five years. The OMB estimate of the
18 Office of Management and Budget, Analytical Perspectives: Budget of the U.S. Government,
Fiscal Year 2009, Table 25-6 (Feb. 2008).
12 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
15. reduction in federal spending produced by this regulation is $3.6 billion over the five-
year period FY 2009 – FY 2013. 19
The Connecticut Medicaid Director points out the contradiction between this regulation
and the policy objective of enrolling more eligible but unenrolled children in Medicaid
and SCHIP:
The proposed regulations would eliminate Medicaid funding for
administrative activities at the schools. The impact on our rates would
approximate $10 million ($5 million in federal financial participation, or
FFP). But more important than the initial fiscal impact would be the effect
that these regulations would have on school outreach. The Administration
intends to hold Connecticut and other states that cover children above
200% of the federal poverty level to an assurance that 95% of the
Medicaid eligible children below 200% FPL are already covered. One of
the best places to conduct outreach to these children is through the
schools, and Governor Rell has dedicated funds in a new initiative to do
exactly that. But this rule would disallow FFP for eligibility
determinations at the schools unless they were performed by staff of the
Department of Social Services. DSS cannot afford to state-fund an
outreach effort in 3,000 schools in 169 towns without the benefit of the
federal match.
G. Case Management Services (CMS 2237-IFC)
As shown in Appendix I, only one of the responding states (Idaho) reported that this
regulation would have no impact on it. 21 of the remaining states were able to estimate a
fiscal impact, while the other 22 did not specify. The 21 states (including the District of
Columbia) estimate that the regulation will reduce federal Medicaid matching payments
to them by a total of $3.1 billion. CMS estimates that the regulation will reduce federal
spending by $1.3 billion over the five-year period FY 2008 – FY 2012. 20
The following observation was offered by the Tennessee Medicaid director:
The recipients of case management services in Tennessee are, by and
large, among the most vulnerable persons in our program — children in
state custody, persons who are mentally ill, persons with mental
retardation, persons who are aged and/or disabled enough to require
nursing facility care, and adults who require protective services to prevent
abuse, neglect, or financial exploitation. It is unfair to make these persons
bear the brunt of CMS’s ‘sledgehammer’ approach to cutting costs, as
exemplified in this rule.
Id.
19
Centers for Medicare & Medicaid Services, Medicaid Program: Optional State Plan Case
20
Management Services 72 Fed. Reg. 68091 (Dec. 4, 2007) (Interim final rule with comment period).
13 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
16. IV. CONCLUSION
The findings presented in this report should be of concern to members of
Congress as well as officials at CMS. They indicate that the CMS Medicaid regulations,
taken as a whole, have fiscal and programmatic impacts that are far more extensive and
far more harmful than has commonly been understood. This lack of policy transparency
in a program that affects the health of 60 million low-income Americans is as regrettable
as it was avoidable.
14 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
17. Appendix A: Medicaid Directors Responding to January 16, 2008 Request
Alaska: Jerry Fuller, Medicaid Director, Department of Health and Social Services,
(907) 465-3030
Arizona: Anthony D. Rodgers, Director, Health Care Cost Containment System, (602)
471-4000
California: Stan Rosenstein, Chief Deputy Director, Health Care Programs, Department
of Health Care Services, (916) 440-7400
Colorado: Joan Henneberry, Executive Director, Department of Health Care Policy and
Financing, (303) 866-2993
Connecticut: David Parrella, Director, Medical Care Administration, Department of
Social Services, (860) 424-5583
Delaware: Harry Hill, Director, Department of Health and Social Services, (302) 255-
9627
DC: Robert T. Maruca, Senior Deputy Director, Medical Assistance Administration,
Department of Health, (202) 442-5988
Florida: Carlton D. Snipes, Acting Deputy Secretary for Medicaid, Florida Medicaid,
(850) 488-3560
Georgia: Mark Trail, Chief, Medical Assistance Plans, Department of Community
Health, (404) 657-1502
Hawaii: Lois Lee, Acting Med-QUEST Division Administrator, Department of Human
Services, (808) 692-8050
Idaho: Leslie M. Clement, Administrator, Division of Medicaid, Department of Health
and Welfare, (208) 334-5747
Illinois: Theresa A. Eagleson, Administrator, Division of Medical Programs,
Department of Healthcare and Family Services, (217) 782-1200
Indiana: Jeffrey M. Wells, Director of Medicaid, Family and Social Services
Administration, (317) 233-4690
Iowa: Eugene I. Gessow, Medicaid Director, Department of Human Services, (515) 725-
1123
Kansas: Andy Allison, Medicaid Director, Health Policy Authority, (785) 296-3981
Kentucky: Elizabeth A. Johnson, Commissioner, Department for Medicaid Services,
Cabinet for Health and Family Services, (502) 564-4321
Louisiana: Jerry Phillips, Medicaid Director, Department of Health and Hospitals, (225)
342-3891
Maine: Tony Marple, Director, Office of MaineCare Services, Department of Health
and Human Services, (207) 287-2674
Maryland: John G. Folkemer, Deputy Secretary of Health Care Financing, Department
of Health and Mental Hygiene, (410) 767-4073
Massachusetts: Tom Dehner, Medicaid Director, Office of Medicaid, Executive Office
of Health and Human Services, (617) 573-1770
Minnesota: Christine Bronson, Medicaid Director, Department of Human Services,
(615) 431-2914
Michigan: Paul Reinhart, Director, Medical Services Administration, Department of
Community Health, (517) 241-7882
15 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
18. Missouri: Ian McCaslin, Director, Division of Medical Services, Department of Social
Services, (573) 751-6922
Montana: John Chappuis, State Medicaid Director, Department of Public Health and
Human Services, (406) 444-4084
Nevada: Charles Duarte, Administrator, Division of Health Care Financing and Policy,
Department of Health and Human Services, (775) 684-3600
New Hampshire: Nicholas A. Toumpas, Commissioner, Department of Health and
Human Services, (603) 271-4912
New Jersey: Clyde H. Henderson, III, Director, Washington Office, State of New
Jersey, (202) 638-0631
New Mexico: Carolyn Ingram, Medical Assistance Division Director, Human Services
Department, (505) 827-3106
New York: Deborah Bachrach, Medicaid Director, Deputy Commissioner, Office of
Health Insurance Programs, Department of Health (518) 474-3018
North Carolina: William W. Lawrence, Jr., Acting Director, Division of Medical
Assistance, Department of Health and Human Services, (919) 855-4100
North Dakota: Maggie D. Anderson, Director, Medical Services Division, Department
of Human Services, (701) 328-2321
Ohio: John R. Corlett, Medicaid Director, Job and Family Services, (614) 752-3739
Oklahoma: Mike Fogarty, Chief Executive Officer, Health Care Authority, (405) 522-
7300
Oregon: Jim Edge, Interim State Medicaid Director, Office of Medical Assistance
Programs, Department of Human Services, (503) 945-5772
Pennsylvania: Michael Nardone, Deputy Secretary, Office of Medical Assistance
Programs, Department of Public Welfare, (717) 787-1870
Rhode Island: Gary D. Alexander, Director, Department of Human Services, (401) 462-
2121
South Carolina: Emma Forkner, Director, Department of Health and Human Services,
(803) 898-2504
South Dakota: Larry Iversen, Medicaid Director, Department of Social Services, (605)
773-3495
Tennessee: Darin J. Gordon, Director, Bureau of TennCare, Department of Finance and
Administration, (615) 507-6000
Texas: Chris Traylor, Medicaid Director, Health and Human Services Commission,
(512) 424-1400
Utah: Michael Hales, Director, Health Care Financing, Department of Health, (801)
538-6689
Virginia: Patrick W. Finnerty, Director, Department of Medical Assistance Services,
(804) 786-7933
Washington: Kathy Leitch, Assistant Secretary, Aging and Disability Services
Administration, Department of Social and Health Services (360) 902-7797; Doug Porter,
Assistant Secretary, Health Recovery Services Administration, Department of Social and
Health Services (360) 725-1867
Wisconsin: Jason A. Helgerson, Medicaid Director, Department of Health and Family
Services, (608) 266-8922
16 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
19. Appendix B: CMS Medicaid Regulations
Estimated
Reduction
Effective Moratorium
Rule Description Federal Funds
Date Status
(OMB) (5 yr.)
Cost Limit for Public
Providers Narrows definition of a public Enacted (sec.
-$5.71 billion
(CMS 2258-FC) provider, limits payments to public July 30, 7002 of P.L. 110-
(FY 2009-FY
Final Rule providers to cost of treating 2007 28); expires May
2013)
72 Fed. Reg. 29748 Medicaid patients 25, 2008
(May 29, 2007)
Payments for Graduate
First full
Medical Education Prohibits federal matching funds for
State FY Enacted (sec.
(GME) costs of GME programs as part of -$1.82 billion
following 7002 of P.L. 110-
(CMS 2279-P) Medicaid reimbursement for (FY 2009-FY
effective 28); expires May
Proposed Rule inpatient or outpatient hospital 2013)
date of 25, 2008
72 Fed. Reg. 28930 services
final rule
(May 23, 2007)
Narrows scope of Medicaid
Redefine Outpatient
outpatient hospital services to “Due to lack of
Hospital Services
Medicare outpatient hospital available data, we
(CMS 2213-P)
services paid on a prospective basis; Not cannot determine
Proposed Rule None
excludes other Medicaid services specified the fiscal impact of
72 Fed. Reg. 55158
(e.g., rehabilitative services) from this proposed
(September 28, 2007)
coverage as outpatient hospital rule.”
services
Allowable Provider Taxes Implements Tax Relief and Health
(CMS 2275-P) Care Act of 2006 (P.L. 109-432) -$430 million
April 22,
Final Rule reduction of threshold from 6% to (FY 2008-FY None
2008
73 Fed. Reg. 9685 5.5% of revenues; substantially 2012)
(February 22, 2008) tightens “hold harmless” test
“We will Enacted (sec. 206
Rehabilitative Services Prohibits federal matching funds for work with of the Medicare,
(CMS 2261-P) rehabilitative services furnished States to -$2.72 billion Medicaid, and
Proposed Rule through a non-medical program implement (FY 2009-FY SCHIP Extension
72 Fed. Reg. 45201 (e.g., foster care, adoption services, this rule in 2013) Act of 2007, P.L.
(August 13, 2007) education, juvenile justice a timely 110-173); expires
fashion….” June 30, 2008
Payments for Costs of
Prohibits federal matching funds for
School Administration, Enacted (sec. 206
(1) administrative activities by
Transportation; of the Medicare,
school employees or contractors and
(CMS 2287-P) -$3.62 billion Medicaid, and
for 2008-2009
Final Rule (FY 2009-FY SCHIP Extension
(2) transportation of school-aged school year
72 Fed. Reg. 73635 2013) Act of 2007, P.L.
children from home to school and
(December 28, 2007) 110-173); expires
back
June 30, 2008
Limits period of coverage for case
Case Management
management services for individuals
Services
transitioning from institutions to the
(CMS 2237-IFC) - $1.28 billion
community; specifies a 15-minute March 3,
Interim Final Rule (FY 2008-FY None
unit of service for all case 2008
72 Fed. Reg. 68077 2012)
management services; bars coverage
(December 4, 2007)
of case management activities as
administrative costs
17 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
20. Appendix C: Estimated Loss of Federal Funds from CMS Regulation on Cost
Limits for Public Providers (CMS 2258-FC)
(In Millions)
STATE FIRST YEAR 5-YEAR TOTAL
Alaska None None
Arizona NS NS
California 943.6 4,718.0
Colorado 142.2 711.0
Connecticut NS NS
Delaware None None
District of Columbia NS 8.7
Florida None None
Georgia 30.2 1,478.0
Hawaii NS NS
Idaho 2.0 10.8
Illinois 255.0 1,300.0
Indiana NS NS
Iowa None None
Kansas None None
Kentucky 21.0 118.0
Louisiana 222.0 1,209.0
Maine 36.0 NS
Maryland NS NS
Massachusetts NS NS
Michigan 225.9 1,254.4
Minnesota 50.5 275.1
Missouri 22.1 110.7
Montana NS 8.6
Nevada NS NS
New Hampshire NS NS
New Jersey 3.0 96.7
New Mexico 168.7 1,444.3
New York 550.0 2,750.0
North Carolina 430.6 2,187.0
North Dakota None None
Ohio 1.4 7.4
Oklahoma None None
Oregon NS NS
Pennsylvania NS NS
Rhode Island NS NS
South Carolina None None
South Dakota None None
Tennessee 200.0 1,000.0
Texas 127.0 2,200.0
Utah 40.7 216.0
Virginia 1.4 7.7
Washington None None
Wisconsin 3.0 15.0
Total 3,476.3 21,126.4
None = State indicated that the regulation would have no impact.
NS = State indicated that the regulation may have an impact but impact not specified.
18 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
21. Appendix D: Estimated Loss of Federal Funds from CMS Regulation on
Graduate Medical Education (GME) (CMS 2279-P)
(In Millions)
STATE FIRST YEAR 5-YEAR TOTAL
Alaska 0.4 3.2
Arizona 30.1 154.7
California 248.2 1,240.0
Colorado 12.0 60.0
Connecticut 4.0 20.0
Delaware 2.7 14.5
District of Columbia NS 73.0
Florida 44.0 220.0
Georgia 5.2 255.3
Hawaii NS NS
Idaho 0.2 0.9
Illinois 14.0 74.0
Indiana NS NS
Iowa 7.1 35.5
Kansas 1.2 5.9
Kentucky 24.0 127.0
Louisiana 103.0 559.0
Maine NS NS
Maryland NS NS
Massachusetts 21.1 115.4
Michigan 104.4 545.8
Minnesota 42.0 233.0
Missouri 91.0 532.3
Montana NS 0.8
Nevada 0.4 2.1
New Hampshire NS NS
New Jersey 3.5 11.5
New Mexico 5.3 26.5
New York 675.0 3,375.0
North Carolina 84.0 420.0
North Dakota None None
Ohio 33.4 NS
Oklahoma NS 250.0
Oregon 21.1 110.7
Pennsylvania 45.4 235.9
Rhode Island None None
South Carolina 62.0 310.0
South Dakota 2.0 10.6
Tennessee 32.0 160.0
Texas 71.0 348.0
Utah 19.3 102.7
Virginia 15.4 85.4
Washington 7.3 38.7
Wisconsin 10.0 50.0
Total 1,841.7 9,807.4
None = State indicated that the regulation would have no impact.
NS = State indicated that the regulation may have an impact but impact not specified.
19 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
22. Appendix E: Estimated Loss of Federal Funds from CMS Regulation on
Outpatient Hospital Services (CMS 2213-P)
(In Millions)
STATE FIRST YEAR 5-YEAR TOTAL
Alaska NS NS
Arizona None None
California 266.4 1,332.0
Colorado NS NS
Connecticut NS NS
Delaware None None
District of Columbia None None
Florida None None
Georgia NS NS
Hawaii NS NS
Idaho None None
Illinois 130.0 700.0
Indiana NS NS
Iowa None None
Kansas None None
Kentucky None None
Louisiana 3.0 19.0
Maine NS NS
Maryland NS NS
Massachusetts NS NS
Michigan None None
Minnesota None None
Missouri 5.9 36.6
Montana None None
Nevada NS NS
New Hampshire NS NS
New Jersey NS NS
New Mexico None None
New York NS NS
North Carolina None None
North Dakota NS NS
Ohio None None
Oklahoma None None
Oregon None None
Pennsylvania NS NS
Rhode Island None None
South Carolina None None
South Dakota NS NS
Tennessee None None
Texas NS NS
Utah None None
Virginia None None
Washington None None
Wisconsin NS NS
Total 405.3 2,087.6
None = State indicated that the regulation would have no impact.
NS = State indicated that the regulation may have an impact but impact not specified.
20 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
23. Appendix F: Estimated Loss of Federal Funds from CMS Regulation on
Provider Taxes (CMS 2275-P)
(In Millions)
STATE FIRST YEAR 5-YEAR TOTAL
Alaska None None
Arizona None None
California 540.0 2,700.0
Colorado None None
Connecticut 60.0 300.0
Delaware None NS
District of Columbia NS 2.6
Florida None None
Georgia None 721.8
Hawaii NS NS
Idaho None None
Illinois 1.7 9.3
Indiana NS NS
Iowa 1.0 NS
Kansas NS NS
Kentucky 126.0 630.0
Louisiana 17.0 92.0
Maine NS NS
Maryland 0.2 NS
Massachusetts None None
Michigan 10.0 10.0
Minnesota NS NS
Missouri 92.9 573.2
Montana None None
Nevada 1.1 5.4
New Hampshire NS NS
New Jersey 2.1 8.4
New Mexico None None
New York NS NS
North Carolina NS NS
North Dakota None None
Ohio NS NS
Oklahoma None None
Oregon 8.5 28.3
Pennsylvania NS NS
Rhode Island 0.3 1.6
South Carolina None None
South Dakota None None
Tennessee 1.5 7.5
Texas 2.1 11.5
Utah None None
Virginia None None
Washington None 2.3
Wisconsin None None
Total 864.4 5,103.9
None = State indicated that the regulation would have no impact.
NS = State indicated that the regulation may have an impact but impact not specified.
21 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
24. Appendix G: Estimated Loss of Federal Funds from CMS Regulation on
Rehabilitation Services (CMS 2261-P)
(In Millions)
STATE FIRST YEAR 5-YEAR TOTAL
Alaska 9.0 45.0
Arizona NS NS
California NS NS
Colorado NS NS
Connecticut 4.5 22.5
Delaware 13.4 72.1
District of Columbia NS 10.6
Florida 32.0 160.0
Georgia None None
Hawaii NS NS
Idaho NS NS
Illinois NS NS
Indiana NS NS
Iowa None None
Kansas NS NS
Kentucky 3.0 15.0
Louisiana NS NS
Maine 17.4 NS
Maryland NS NS
Massachusetts 64.6 382.2
Michigan 321.6 1,729.0
Minnesota NS NS
Missouri None None
Montana NS NS
Nevada 9.5 50.4
New Hampshire NS NS
New Jersey 4.5 55.0
New Mexico NS NS
New York 202.0 1,010.0
North Carolina NS NS
North Dakota NS NS
Ohio NS NS
Oklahoma NS 42.5
Oregon 72.9 378.6
Pennsylvania NS NS
Rhode Island 125.7 628.5
South Carolina 18.0 90.0
South Dakota NS NS
Tennessee NS NS
Texas 14.2 356.3
Utah 2.4 13.0
Virginia NS NS
Washington 33.2 166.0
Wisconsin NS NS
Total 947.9 5,226.7
None = State indicated that the regulation would have no impact.
NS = State indicated that the regulation may have an impact but impact not specified.
22 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
25. Appendix H: Estimated Loss of Federal Funds from CMS Regulation on
School Administration and Transportation Costs (CMS 2287-P)
(In Millions)
STATE FIRST YEAR 5-YEAR TOTAL
Alaska 8.0 40.0
Arizona 11.7 58.5
California 130.0 650.0
Colorado 1.4 7.0
Connecticut 5.0 25.0
Delaware 1.2 6.4
District of Columbia NS 17.5
Florida 57.0 285.0
Georgia None 57.6
Hawaii NS NS
Idaho 0.0 0.2
Illinois 82.0 429.0
Indiana NS NS
Iowa NS NS
Kansas 3.2 16.5
Kentucky 13.0 65.0
Louisiana 5.0 25.0
Maine NS NS
Maryland 1.0 NS
Massachusetts 47.3 246.6
Michigan 22.0 116.8
Minnesota None 40.1
Missouri 28.5 142.5
Montana NS 9.0
Nevada 0.8 4.5
New Hampshire NS NS
New Jersey 15.8 90.0
New Mexico 2.8 14.0
New York 44.0 220.0
North Carolina NS 56.0
North Dakota None None
Ohio NS NS
Oklahoma None None
Oregon 10.3 54.8
Pennsylvania 35.0 191.5
Rhode Island 1.9 9.5
South Carolina 9.5 47.5
South Dakota 5.4 27.9
Tennessee None None
Texas None 49.0
Utah 2.5 13.5
Virginia 25.1 138.8
Washington 9.4 47.0
Wisconsin 10.8 54.0
Total 589.6 3,255.7
None = State indicated that the regulation would have no impact.
NS = State indicated that the regulation may have an impact but impact not specified.
23 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS
26. Appendix I: Estimated Loss of Federal Funds from CMS Regulation on
Case Management Services (CMS 2237-IFC)
(In Millions)
STATE FIRST YEAR 5-YEAR TOTAL
Alaska NS NS
Arizona NS NS
California 24.0 119.0
Colorado 1.8 9.2
Connecticut 10.0 50.0
Delaware NS NS
District of Columbia NS 80.0
Florida NS NS
Georgia None 63.9
Hawaii NS NS
Idaho None None
Illinois 5.0 26.0
Indiana NS NS
Iowa NS NS
Kansas NS NS
Kentucky 37.0 200.0
Louisiana NS NS
Maine 17.5 NS
Maryland 66.2 NS
Massachusetts 54.6 284.0
Michigan 48.3 254.0
Minnesota 8.7 210.5
Missouri NS NS
Montana NS NS
Nevada NS NS
New Hampshire NS NS
New Jersey NS 95.7
New Mexico 6.4 33.4
New York NS NS
North Carolina NS NS
North Dakota NS 13.3
Ohio NS NS
Oklahoma NS 195.0
Oregon 52.0 288.0
Pennsylvania NS NS
Rhode Island 1.4 7.0
South Carolina NS NS
South Dakota NS NS
Tennessee 70.0 350.0
Texas 37.5 431.0
Utah 2.8 15.4
Virginia NS NS
Washington 61.0 334.0
Wisconsin 15.0 75.0
Total 519.2 3,134.4
None = State indicated that the regulation would have no impact.
NS = State indicated that the regulation may have an impact but impact not specified.
24 | THE ADMINISTRATION’S MEDICAID REGULATIONS: STATE-BY-STATE IMPACTS