Medicaid Overview

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MERCATUS RESEARCH

MEDICAID OVERVIEW Jason Fichtner and John Pulito

Bridging the gap between academic ideas and real-world problems

 

ABOUT THE MERCATUS CENTER AT GEORGE MASON UNIVERSITY at George Mason University is the world’s premier university source for market-oriented ideas—bridging the gap between academic ideas and real-world problems. The Mercatus Center

 A univers u niversity-base ity-based d research r esearch center, Mercatus advance advancess knowled k nowledge ge about how markets work to improve people’s lives by training graduate students, conducting research, and applying economics to offer solutions to society’s most pressing problems. Our mission is to generate knowledge and understanding of the institutions that affect the freedom to prosper and to find sustainable solutions that overcome the  barriers preventing preventing individuals individuals from living free, prosperous, and peaceful peaceful lives. lives. Founded in 1980, the Mercatus Center is located on George Mason University’s  Arlington campus. campus.

www.mercatus.org 

Copyright © 2013 by Jason J. Fichtner and John Pulito and the Mercatus Center at George Mason University 

Mercatus Center George Mason University  3351 Fairfax Drive, 4th floor  Arlington, VA VA 22201-4433 22201-4433 (703) 993-4930 mercatus.org  Release date: xx, 2013

 

ABOUT THE AUTHORS Jason J. Fichtner is a senior research fellow at the Mercatus Center at George Mason University. His research focuses on Social Security, federal tax policy, federal budget policy, retirement security, and policy proposals to increase saving and investment. John Pulito is an alumnus of the Mercatus MA fellowship at George Mason University. He is in an economic consulting position for the federal government.

 

MERCATU US S CENTER AT GEORGE MA SON UNIVERSITY

ABSTRACT This paper provides an

overview of the intent of the Medicaid program and its  budgetary implications. implicatio ns. In 1965, when Medicaid was created c reated under Title XIX of the Social Security Act to provide health insurance for low-income individuals, the program was considered an afterthought to Medicare. Today, however, more  Americans receive coverage from Medicaid than any other health insurance program, including Medicare. Today Medicaid costs nearly $500 billion annually, funded by taxpayer dollars at the state and federal levels. This paper explains the  budgetary implications impli cations of Medicaid for federal and state stat e budgets and how these obligations will grow under the Patient Protection and Affordable Care Act.

 JEL codes:  JEL  codes: I13, I18, H750, H510 Keywords: Medicaid, Affordable Care Act, State Spending, Federal Spending, FMAP

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afterthought to the Medicare program, Medicaid was signed into law under Title XIX of the Social Security Act. Unlike Medicare, which was created to provide health care coverage to those over the age of 65, Medicaid’s intent was the provision of care for individuals of any age who were financially limited. In 1966, Medicaid provided health insurance to 10 million beneficiaries.1 Currently with approximately 57 million people enrolled, Medicaid has evolved into the largest health insurance provider in the United States.2

O

ften called an

This policy brief will provide overview of the Medicaid system, its budget implications at the state and federalan levels, and the implications of the Patient Protection and Affordable Care Act (ACA) for states’ Medicaid programs.

WHAT IS MEDICAID? Medicaid is a government health insurance program providing providi ng coverage to individuals who are limited in their ability to pay for medical care. The program is run by the states using federal cost sharing dollars. Though state participation in Medicaid is voluntary, voluntary, all 50 states and the District of Columbia participate. Each state, using federal matching funds, establishes and administers its own Medicaid program. As long as a state follows federal guidelines, it has the flexibility to determine the type and scope of services provided. Additionally, each state has the option of charging enrollees’ premiums and establishing out-of-pocket out-of-pocket spending requirem requirements ents such as copayments, coinsurance, and deductibles.  Although Medica Medicaid id eligibil eligibility ity varies dramati dramatically cally from state to state, in order to qualify for federal funding each state must provide coverage coverage to limited income families with children as well as individuals individ uals who are aged, blind, or o r disabled (see the percent3 age breakdown in figure 1 on the next page).

1. 2. 3.

J. K. Iglehart, “The Dilemma of Medicaid,” Medicaid,” New  New England Journal of Medicine Medicine 348,  348, no. 21(2003): 2140–8; Centers for Medicare and Medicaid Services, CMS Financial Report, Fiscal Year 2010 (2010). 2010  (2010). Centers for Medicare and Medicaid Services, CMS Financial Report, Fiscal Year 2012 (2012). 2012  (2012). “Eligibility,” Medicaid.gov., Center for Medicaid Medicaid and CHIP Services Services (CMCS), (CMCS), accessed November 19, 2013.

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MERCATU US S CENTER AT GEORGE MA SON UNIVERSITY

FIGURE 1 – FISCAL YEAR 2012 MEDICAID ENROLLEES 4

Adult, 23%

Child, 50%

Aged, 9%

Disabled, 18%

Though the income threshold varies by state, an individual or family applying for Medicaid cannot exceed a certain income threshold, which is calculated in relation to a percentage of the Federal Poverty Level (FPL). Today, the FPL ranges from $11,490 for a family of one to $39,630 for a family of eight. 5 For example, consider a pregnant woman comprising a family of one and a nd fitting categorically into one of Medicaid’s mandatory eligibility groups. In 2013, the median (across 50 states and the District of Columbia) Medicaid threshold threshold for this individual was 185 percent of the 6 FPL.  Therefore, she would be eligible for Medicaid if she earned less than $21,257. It is important to note that states may offer a greater number and additional types of services offered that go above and beyond what is mandated by the Department of Health and Human Services (HHS). Through Section 1115 of the Social Security Act, the federal government has encouraged states to tailor the Medicaid program to their unique political and economic environments. 7 Building upon Section 1115 of the Social Security Act, the Health Insurance Flexibility and Accountability (HIFA) demonstration initiative gives states enhanced “waiver flexibility to streamline benefits packages, create public-private partnerships, and increase cost-sharing for optional and expansion populations covered under Medicaid.”8 Contingent on approval by the HHS Secretary, leaders are empowered to develop a unique program that meets their states needs.

4. 5. 6.

7. 8.

CMS, Financial CMS,  Financial Report, Report, 2012. 78 Fed. Reg. 5182–3 (January 24, 2013). M. Heberlein, Heberlein, T. Brooks, Brooks, and and J. Alker, Alker, “Getting into Gear for 2014: Findings from from a 50-State Survey Survey of Eligibility, Enrollment, Renewal, and Cost-Sharin Cost-Sharing g Policies in Medicaid and CHIP, 2012–2013,” The Henry J. Kaiser Family Foundation, January 2013. G. Engquist Engquist and and P. Burns, “Health Insurance Flexibility and and Accountability Accountability Initiative: Initiative: Opportunities Opportunities and Issues for the States,” State States,” State Coverage Initiatives Initiatives 3,  3, no. 2 (2002): 1–6. Ibid.

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MERCATU US S CENTER AT GEORGE MA SON UNIVERSITY

HOW MEDICAID IS FUNDED Medicaid is a matching-grant program jointly funded by federal and state governments. To determine the share of Medicaid the federal government will pay in each state, the HHS calculates the Federal Medical Assistance Percentage (FMAP): 9    = 1

− 0.45

 ∗

      

 !

          !

 

Instituted in 1965, the FMAP formula ensures that the federal government pays a higher proportion of Medicaid costs cos ts in states where the average income per capita is lower relative to the national average. Using income data averaged over three years, the HHS provides an updated FMAP value every fiscal year between October 1 and Novemberr 30. For purposes of this formula, “income” represents personal income Novembe as calculated by the Bureau of Economic Analysis instead of money income as calculated by the Census Bureau. Burea u. To control the amount paid by either the federal or state government, threshold limits bind the FMAP between 50 and 83 percent. 10 FMAPs as of Fiscal Year 2012 are shown in figure 2 below. FIGURE 2 – FEDER AL MEDICAL A SSISTANCE PERCENTAGES, PERCENTAGES, FISCAL YEAR 201211

 

STATE

FMAP

Alabama

68.62%

Kentucky

71.18%

North Dakota

55.40%

Alaska

50.00%

Louisiana

61.09%

Ohio

64.15%

Arizona

67.30%

Maine

63.27%

Oklahoma

63.88%

Arkansas

70.71%

Maryland

50.00%

Oregon

62.91%

California

50.00%

Massachusetts

50.00%

Pennsylvania

55.07%

Colorado

50.00%

Michigan

66.14%

Rhode Island

52.12%

Connecticut

50.00%

Minnesota

50.00%

South Carolina

70.24%

Delaware

54.17%

Mississippi

74.18%

South Dakota

59.13%

District of Columbia*

70.00%

Missouri

63.45%

Tennessee

66.36%

Florida

56.04%

Montana

66.11%

Texas

58.22%

Georgia

66.16%

Nebraska

56.64%

Utah

70.99%

Hawaii

50.48%

Nevada

56.20%

Vermont

57.58%

Idaho

70.23%

New Hampshire

50.00%

Virginia

50.00%

Illinois

50.00%

New Jersey

50.00%

Washington

50.00%

Indiana

66.96%

New Mexico

69.36%

West Virginia

72.62%

Iowa

60.71%

New York

50.00%

Wisconsin

60.53%

Kansas

56.91%

North Carolina

65.28%

Wyoming

50.00%

  * The values for the District of Columbia in the table were set for the state plan under titles XIX and XXI and for capitation payments and DSH allotments under those titles. For other purposes, the percentage DC is 50.00, unless otherwise specified by law.

9. 10. 11.

National Health Policy Forum: Forum: George Washington University, “The Basics: Medicaid Financing” (2013). Ibid. 75 Fed. Reg. 69082-59083 (November 10, 2010).

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MERCATU US S CENTER AT GEORGE MA SON UNIVERSITY

THE PATIENT PROTECTION AND AFFORDABLE CARE ACT In an attempt to increase the number numbe r of Medicaid recipients, the ACA as it was wa s originally written created a new category of individuals eligible for Medicaid. Without noting the specific caveats, this category extended coverage coverage to all individuals whose incomes fell below 133 percent of the FPL (accounting for a 5 percent federal income exclusion, this threshold effectively effectively increases to 138 percent of the FPL) who were not previously eligible for Medicaid. 12,13 Based on an estimate from the Centers for Medicare and Medicaid Services, this coverage expansion was estimated to increase total projected Medicaid enrollment by 14.9 million people in 2014 and 25.9 million people by 2020.14 Under current law, the HHS Secretary is permitted to withhold federal funding if a state fails to comply with the minimum benefit and eligibility requirements requirements established by the federal government. Originally, the ACA stipulated that states that failed to expand their Medicaid coverage would be considered noncompliant. In its review of the ACA’s constitutionality, the Supreme Court held that the Medicaid expansion clause in the ACA was unconstitutionally coercive.15 Chief Justice John Roberts’s opinion held that the mandatory expansion of Medicaid coupled with the HHS secretary’s authority to withhold for of noncompliance is abudget “gun to head”  because the “threatened loss offunding 10 percent a State’s Stat e’s overall is the economic dragooning that leaves the States with no real option but to acquiesce.”16 To allow the provisions set forth in the ACA to remain intact while providing a remedy for the coercion inherent in the act, the Supreme Court precluded the HHS Secretary’s ability to withhold existing Medicaid funds for failing to comply with the Medicaid expansion requirements, leaving only the “carrot” of increased funding to encour encour-17 age states to expand Medicaid eligibility.  For newly eligible individuals, the federal government will pay 100 percent of the costs for the first three years. Starting in 2017, the percentage paid will decrease and ultimately settle at 90 percent in 2020. 18

MEDICAID AND THE COST IMPLICATIONS OF THE ACA The Supreme Court’s ruling effectively relegates the choice to expand Medicaid to the states. From a state’s perspective, the decision to expand coverage depends on two competing values. Charles Blahous, a public trustee for Social Security and Medicaid, recently analyzed the incentives facing states under the ACA. He finds that a state governor faces an incentive to “maximize the health benefits his own 12. 13. 14. 15. 16. 17. 18.

National Conference Conference of State Legislatures. Legislatures. “The “The Affordable Affordable Care Act: A Brief Summary” Summary” (March 2011). CMS, Financial Report, CMS, Financial Report, 2011. Ibid. The Henry J. Kaiser Family Foundation, “A Guide to the Supreme Court’s Affordable Care Act Decision” (July 2012). National Federation Federation of of Independent Business Business v. v. Sebelius, 567 567 U. S. ____ (2012), at 51. Ibid. National Health Policy Forum, “Medicaid Financing,” 2013.

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MERCATU US S CENTER AT GEORGE MA SON UNIVERSITY

FIGURE 3 – PROJECTED MEDIC AID EXPENDITURES (A SSUMES UNIVERSAL PARTICIPATION) PARTICIPATION)21

$1,000

1960 1961 1962 1963 1964 Total Tot al Nati National onal Hea Health lth Expe Expendit nditure uress $ 27,3 27,359. 59.00 00 $ 29,229.00 $ 31,907.00 $ 34,727.00 $ 38,544.00 $ 41,95 $900 Medicaid (Title XIX) $ $ $ $ $ $ Federal $ $ $ $ $ $ $800

State and Local $    e   s    t    e    a   r    t    u    t    S   i    d   d    n   n   )    a   e   s    l    p   n    a   x   o    l    r    E   i    l    i    e    B    d   d    (    e   i    F   a    c    l    i    a   d    t    e    o    T   M

-

$

-

$

-

$

-

$

-

$

$700 $600 $500 $400

Medicaid (Title XIX) $ Pr Priv ivat ate e Heal Health th Insu Insuran rance ce $ $300 Nominal GDP $200 Real GDP (1995 $s) Real GDP (Chain 2005 $s) $100 Real GDP (Chain 2011 $s) Real Federal Medicaid $-State and Real Local Medicaid 2012 2013 State and Local Expenditures

5,779 5,779.0 .00 0

2014

$ $

2015

6,419.00

$ $

2016

7,113.00

2017

$ $

2018

7,887.00

$ $

2019

8,982.00

2020

$ $ 10,00

2021

FIGURE 4 - MEDIC AID EXPENDITURES A S A PERCENTAGE OF TOTAL TOTAL US HEALTH CARE EXPENDITURES 23

25%

Total Tot al Nati Nationa onall Hea Health lth Exp Expend enditur itures es Medicaid (Title XIX) Federal 20% State and Local    s    e    r    u

1960 27,359. 27,359.00 00 -

1966 - 2011 (Actual)

$ $ $ $

$ $ $ $

1961 29,229.00 -

$ $ $ $

1962 31,907.00 -

$ $ $ $

1963 34,727.00 -

6,419.00

$ $

7,113.00

$ $

199 1

1996

2012 196- 42021 Projected

$ 38,544.00 $ $ $ -

1 $ 41,957. $ $ $ -

7,887.00

$ $

$ $ 10,000.

2006

2011

 

   l    i    a   t    t    d 15%    o   n    T   e    f    p    o   x    t    E    n   e    e   r    c   a    r    C    e    h 10%    P   t    l    a    e    H

Medicaid (Title XIX) $ $ Pr Priv ivate ate Heal Health th Insur Insuran ance ce $ 5,779 5,779.0 .00 0 $ Nominal GDP 5% Real GDP (1995 $s) Real GDP (Chain 2005 $s) Real GDP (Chain 2011 $s) Real Federal Medicaid 0%Real State and Local Medicaid 1966 1971 1976 1981 1986 State and and Local Ex enditur enditures es

2001

8,982.00

  9

2016

2021

 

MERCATU US S CENTER AT GEORGE MA SON UNIVERSITY

state’s citizens receive that are financed by entities outside of the state, while also minimizing his state’s budgetary budget ary exposure.”19 From state policymakers’ perspectives, the decision to expand coverage is complex. Though the federal government agreed to cover a significant portion of associated expenses in order to influence states to expand Medicaid, each state must project how the Medicaid expansion will impact its current and future budgets. Considering Medicaid represented less than three percent of total state and local expenditures in 1967, whereas in fiscal year 2012 it represents an estimated 24 percent of total expenditure expenditures, s, it is unlikely expenditures  20 will decrease in the foreseeable future. futu re.  The trend is clearly clearl y visible in figure figu re 3 below. Based on preliminary estimates from the Centers for Medicare and Medicaid Ser vices (CMS), Medicaid expenditures expenditures per year are are expected to increase increase by approxiapproximately $500 billion between 2012 and 2021—roughly a 108 percent increase.22 (See figure 4 below.) It is important to note that CMS assumes universal expansion of the Medicaid program to include the ACA intended beneficiary group. While one may argue that it is incorrect to assume universal participation, the issue of increasing Medicaid expenditures has plagued the health insurance insu rance program since its inception. The amount of money spent on Medicaid continues to represent a significant portion of total health care expenditures in the United States. State s. It is important to note that projections are not allocated between federal and state & local governments. The problems associated with Medicaid expenditures are further evidenced in figure 5 on the next side.  Adjusting for inflation, the amount of money spent on Medicaid has significantly increased since the program was first adopted. While one may be tempted to argue that this increase can be solely attributed to rising health care costs, research shows that this increase can be primarily attributed to “changing demographics, increased access and eligibility, service expansions, and a nd waste.”25 Regardless of the cause, Medicaid continues to become a larger share of state budgets. (See figure 6 on the next page.) For fiscal year 2012, Medicaid represented roughly 24 percent of state budgets. To reflect the likelihood that not every state in the country will expand Medicaid eligibility, the Congressional Budget Office (CBO) released a revised report in June 19.

20. 21. 22. 23. 24. 25.

Charles Blahous, “The Affordable Care Act’s Optional Medicaid Expansion: Considerations Facing State Governments” (Mercatus Research, Mercatus Center at George Mason University, Arlington,  VA, March 2013) 20. National Association of State Budget Officers, The Fiscal Survey of States, 2012 (2012); 2012 (2012); US Department of Commerce. Statistical Commerce. Statistical Abstract of the United States States, 90th ed. (1969). CMS, National Health Expenditure CMS, National Expenditure Data (2012).. Data (2012).. Ibid. Ibid. bid. Scott Beaulier Beaulier and Brandon Brandon Pizzola, “The Political Political Economy of of Medicaid: Evidence Evidence from Five Reforming States” (Mercatus on Policy, Mercatus Center at George Mason University, Arlington,  VA, April 2012). 2012).

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MERCATU US S CENTER AT GEORGE MA SON UNIVERSITY

FIGURE 5 – HISTORICAL FEDERAL AND STATE MEDICAID SPENDING 24

$450

1960 1961 1962 1963 1964 19 Total Natio National nal Health Expend Expenditures itures $ 27,359. 27,359.00 00 $ 29,229.00 $ 31,907.00 $ 34,727.00 $ 38,544.00 $ 41,957.0 $400

$350

   g   )    n    i    s    d   $    n   2    e   1    p   0    S   2  ,    s    d    i    n    a   o    c   l    i    i    i    d   l    e   B    (    M

Medicaid (Title XIX) $ Federal $ State and Local $

-

$ $ $

-

$ $ $

-

$ $ $

-

$ $ $

-

$ $ $

-

$300 $250 $200 $150 $100 $50

Medicaid (Title XIX) $ Pr Priv ivat ate e Heal Health th Insu Insuran rance ce $ Nominal GDP Real GDP (1995 $s) Real GDP (Chain 2005 $s)

Real GDP (Chain 2011 $s) Real Federal Medicaid 1966 1971 1976 Real State and Local Medicaid State and Local Expenditures

$ 5,77 5,779. 9.00 00 $

6,419.00

$ $

7,113.00

$ $

7,887.00

$ $

8,982.00

$ $ 10,000.0

 $-

198 1

1986

Federal

1991

1996

2001

2006

2011

State and Local

FIGURE 6 - MEDICAID EXPENDITURES AS A SHARE OF TOTAL STATE BUDGETS  26

 

alth alth Expend Expenditu itures res edicaid (Title XIX) Federal State and Local

$ $ $ $

1960 27,3 27,359. 59.00 00 -

$ $ $ $

1961 1962 1963 29,229.00 $ 31,907.00 $ 34,727.00 $ $ $ -24% $ Medicaid, $ $ -

$ $ $ $

1964 38,544.00 -

$ $ $ $

$ $

8,982.00

$ $

All Other, 38% Transportation 8%

   

edicaid (Title XIX) $ He Heal alth th In Insu sura ranc nce e $ Nominal GDP eal GDP (1995 $s) P (Chain 2005 $s) P (Chain 2011 $s)  

$ 5, 5,77 779. 9.00 00 $

$ 6,419.00 $ 7,113.00 Education, 30%

$ $

7,887.00

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MERCATU US S CENTER AT GEORGE MA SON UNIVERSITY

2012 with updated cost estimates. Though the revised estimate suggests that the total Medicaid outlays between 2012 and 2022 will be approximately $289 billion less than originally planned, it projected that federal government exchange subsidies and related spending will increase by $209 billion.27 This revised estimate warrants further clarification. To this point, this report has focused solely on the expansion of the Medicaid program. Though no state is required to expand eligibility, every state is required to establish a health insurance exchange (hereafter cited in text as exchange). In its simplest form, an exchange is a virtual marketplace where qualified individuals and small businesses can purchase health insurance. insu rance. The exchange will help facilitate the purchase of a health insurance plan by allowing individuals and businesses the ability to compare benefits and prices of different plans. In implementing the mandated exchanges, each state has the option to either operate its own exchange (assuming approval by the HHS Secretary) or opt for a federally facilitated exchange. 28 Though numerous stipulations exist, an applicant appli cant in the exchange may be eligible for federal subsidies to help pay for an insurance policy offered through the exchange. To be considered for such subsidies, an applicant must not be eligible for “minimum essential coverage” except through the individual health insurance market or an employer-sponsored employer -sponsored plan that is either deemed unaffordable or does not provide an  ACA-mandated  ACA-mandate d minimum value. The The applicant’s applicant’s income must fall between 100 and 29 400 percent of the FPL.  Minimum essential coverage is defined as coverage under: (1) a government-sponsored government-sponsored plan; (2) an employer sponsored plan; (3) plans in the individual market; (4) grandfathered health plans; (5) or any other health benefits coverage recognized by the HHS Secretary. 30 It is important to highlight the threshold established established by the ACA because it creates a new incentive for state governments. The ACA effectively created a new beneficiary group characterized by individuals who were previously ineligible for Medicaid and whose income fell below 133 percent. For states that opt to expand coverage, research suggests coverage will only be expanded for individuals making below 100 percent of the FPL. For a state governor who values maximizing externally financed health  benefits while minimizing mi nimizing exposure to the state’s budget, this type ty pe of expansion would allow citizens to experience higher quality health care at no additional cost to the state.31

26. 27.

NASBO, Fiscal Survey of States, NASBO, Fiscal States, 2012. Congressional Budget Office. “Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision” (2012). 28. Bernadette Fernandez, and Annie L. Mach, “Health Insurance Exchanges under the Patient Protection and Affordable Care Act (ACA),” Congressional Research Service. R42663 Service. R42663 (2013). 29. Ibid. 30. Annie L. Mach, M. Scales, and J. Mulvey, “Individ “Individual ual Mandate and Related Information Requirements under ACA,” Congressional Research Service R41331 Service R41331 (July 22, 2013). 31. Blahous, “ACA’s Optional Medicaid Expansion,” 2013.

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MERCATU US S CENTER AT GEORGE MA SON UNIVERSITY

Unfortunately, this incentive is likely to have a significant impact on the federal government’s budget between now and 2022. Assuming that the HHS Secretary allows partial expansion, CBO revised estimates suggest that exchange insurance subsidies and other related spending are expected to cost $1.017 trillion between now and 2022—with costs starting to gradually increase in 2014. 32

CONCLUSION Given that the ACA is still in its infancy, it is imperative to consider how this significant change will affect state and federal budgets and the economy at large. To emphasize this point, consider figure 7. Examining the data between 2000 and 2036, it is clear that the two largest government health care programs in the country are slowly beginning to represent a larger share of Gross Domestic Product (GDP). With non-interest spending at 22 percent of GDP, it is clear that government health care spending is at unprecedented levels. With or without Medicaid eligibility expansion, Medicaid is on a trajectory to require increasing resources at state and federal levels of government, creating difficult budgetary tradeoffs for both.

FIGURE 7 – HEALTH EXPENDITURES AS A PERCENTAGE OF GROSS DOMESTIC PRODUCT33

$450

Total Nation National al Healt Health h Expend Expenditures itures $400 Medicaid (Title XIX) Federal $350 State and Local    g   )    n    i    s    d   $    n   2    e   1    p   0    S   2  ,    d   s    i    a   n    c   o    i    i    l    i    d   l    e   B    (    M

$ $ $ $

1960 27,35 27,359.00 9.00 -

$ $ $ $

1961 29,229.00 -

$ $ $ $

1962 31,907.00 -

$ $ $ $

1963 34,727.00 -

$ $ $ $

1964 38,544.00 -

6.00%

1965 $ 41,957.00 $ 5.00% $ $ 4.00%

$300 $250

3.00% $200 2.00% Medicaid (Title XIX) $ $ $ $ $ $ Priv Pr ivat ate e Healt Health h Insu Insura ranc nce e $ 5, 5,77 779. 9.00 00 $ 6,419.00 $ 7,113.00 $ 7,887.00 $ 8,982.00 $ 10,000.00 $100 Nominal GDP 1.00% Real GDP (1995 $s) $50 Real GDP (Chain 2005 $s) Real GDP (Chain 2011 $s) 0.00% $Real Federal 1992 1993 1994Medicaid 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Real State and Local Medicaid State and Local Expenditures State and Local Federal Percent of State and Local Expenditures $150

32.

Congressional Budget Office, Office, Estimates  Estimates for the Insurance Coverage Provisions Provisions of the Affordable Care  Act Updated for the the Recent Supreme Court Decision Decision (2012).  (2012). 33. Congressional Budget Office. The 2012 Long-Term Budget Outlook (2012). Outlook (2012).

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