50 Reasons Medicaid Expansion is Good for Your State
Prepared by Jane Perkins
August 2, 2012
Medicaid Expansion and States:
1. The Medicaid Expansion is an exceptionally generous deal for the states. Stateswill receive 100% federal funding for the expansion population for the first threeyears, to be gradually reduced to 90% thereafter. Between 2014 and 2022, a fullyimplemented Medicaid Expansion will cover 17 million lower-income people whileincreasing direct state Medicaid spending by only 2.8% more than if healthreform had not been enacted.1These figures do not reflect savings that will beproduced elsewhere as the ACA is implemented (see below). When thesesavings are factored in, states are expected to save an estimated $101 billionfrom 2014-2019.2
2. The Medicaid Expansion will generate savings for some states’ Medicaidprograms. Between 2014 and 2019, a few states will save money by making theExpansion: HI, ME, MA, and VT. Other states will experience an increase of lessthan 1% in their state Medicaid spending, including AZ, DE, DC, NY, ND, SD, WIand WY.3
3. The Medicaid Expansion will help free up state and local spending that now goesto uncompensated care. State and local governments help offset the cost of carethat is provided to uninsured patients who cannot afford to pay—paying anestimated 30% of the cost of uncompensated care. The ACA will roughly halvestate spending on uncompensated care, generating savings of $26-$52 billion.4
4. The Medicaid Expansion will reduce state spending on mental health services forlower-income, uninsured patients. This includes spending on state mentalhospitals, hospital emergency rooms and community health clinics. Thisspending has been growing over time, with state and local governments covering42% of the cost of state mental health expenditures by 2009.5Full MedicaidExpansion is estimated to save between $11 and $22 billion in funds states willotherwise spend on mental health programs from 2014-2019.6
5. The Medicaid Expansion will enable states to continue using health care providerassessments as part of their state matching funds. Although federal Medicaidfunding to states is open-ended (i.e. a state entitlement), it is limited by a states’ability to raise its matching share. Some states have taken advantage of federalprovisions that place assessments on hospitals and other health care providersthat are then used to match (and draw down additional) federal dollars.7 Withoutthe Medicaid Expansion, hospitals and other providers may be unwilling orunable to pay these assessments, resulting in the loss of federal funds and anegative impact on state and local governments.
6. The Medicaid Expansion will avoid costs associated with transitions andchurning. As individuals change jobs or fall in and out of work, income andeligibility for health insurance coverage fluctuate. Medicaid Expansion willprovide stability in coverage; for example, individuals whose income moves themabove 100% of the poverty line can remain in Medicaid and thus with the sameproviders.8 Stability in coverage means lower administrative costs. Stability incoverage improves continuity of care and the health care provider’s ability toprovide good care.9The ACA includes numerous options for state Medicaidprograms to improve continuity of care; expansion will allow the affectedpopulations to take advantage when a state elects these options.10
7. The Medicaid Expansion will keep residents’ federal taxes flowing into the State. Almost every state resident pays federal taxes, and federal dollars will fund theMedicaid Expansion. Taxpayers residing in states that do not implement theExpansion will be paying out dollars to states that do expand, states like CA, CT,CO, DC, MN, MO, NJ, WA, which have already obtained approval for MedicaidExpansions.11
8. The Medicaid Expansion could help avoid work force flight. States could losevaluable members of the work force, as some low-income working adults willmove to states that are making Medicaid coverage available.
9. The Medicaid Expansion will attract managed care to the state. Medicaidmanaged care companies are experiencing some of the fastest growth amongU.S. managed care firms. They are aggressively seeking to move into states thatimplement the Medicaid Expansion, as states have been actively seeking tomove more of their Medicaid populations into managed care.12 States that do notimplement the Medicaid Expansion will lose this population group as part of theirbusiness and bargaining strategy.
10.The Medicaid Expansion will have a deep and broad impact on the stateeconomy. New federal Medicaid dollars will travel through the state economy,improving employment, labor income, and capital income. New federal dollarswill turn over multiple times in the state economy (for example, from physician toemployee to grocer).13
11.The Medicaid Expansion will generate revenue. State and local revenues willincrease when state residents pay income, sales, and other taxes generated bythe federal funding for the Medicaid Expansion, which in some states will offsetmuch, perhaps all, of the additional costs.14 These increased state income taxesare a major factor in the Arkansas Department of Human Services’ estimate thatthe Expansion will save the state $372 million in the first several years.15
Medicaid Expansion and Health Care Providers:
12.The Medicaid Expansion will help hospitals caring for a disproportionate share oflow-income and uninsured people. Many community and public hospitals havebeen receiving enhanced federal funding, called Medicare and Medicaiddisproportionate share hospital (DSH) funding, to compensate them for some ofthe costs associated with treating large numbers of the uninsured. On theassumption that the number of uninsured people will fall dramatically beginning in2014 when the individual mandate and Medicaid Expansion take effect, the ACAdecreases DSH payments.16 In states that do not expand Medicaid, the need foruncompensated care may remain relatively stable, while the amount of DSHfunds that can be used to subsidize some of that care will fall substantially. Thismay result in severe financial hardship for hospitals, meaning that they willincrease costs to paying patients or provide less uncompensated care.
13.The Medicaid Expansion will reduce use of costly hospital departments. Uninsured people often cannot find a regular source of care and depend onhospital emergency departments for emergency and non-emergency care. Emergency room care is expensive. By contrast, once people get Medicaid, theyuse the hospital emergency department at the same rate as people who haveprivate insurance for both emergency and non-urgent care. As with the privatelyinsured, most of the Medicaid visits to the emergency room are for urgent orserious issues.17 Fewer people in ERs means less waiting time for people withreal emergencies, which includes everyone regardless of income.
14.The Medicaid Expansion could help safety net and low-profit margin hospitalskeep their emergency departments open. From 1990 to 2009, the number ofhospital emergency departments in non-rural areas declined by 27%.18 Medicaidfunding for uninsured patient care could help emergency departments open.
15.The Medicaid Expansion will be a source of revenue for hospitals, regardless ofwhat the Independent Payment Advisory Board decides. The ACA establishesthe Independent Payment Advisory Board, which must propose measures toreduce Medicare spending in years when spending growth will outpace targetgrowth rates. The proposals cannot ration care, raise revenue by increasingbeneficiary cost-sharing or reducing services, and until 2019 cannot reduce someprovider (e.g. hospital) payment rates.19 In years when the targets are not met,the IPAB’s proposals to reduce Medicaid spending could mean that hospitals willface even deeper cuts in states that do not implement the Medicaid Expansion.
16.The Medicaid Expansion will benefit community health centers. Federally fundedhealth centers are the main source of primary care for medically underservedpopulations. The Expansion will enable these centers to expand capacity toserve the uninsured as well as those newly covered by Medicaid. Fullyimplemented by the states, the Medicaid Expansion will allow health centers toreach approximately 19.8 million new patients. Without the Expansion, healthcenters’ new patient care capacity will be reduced by nearly 27%, a 5.3 milliondrop in new patients.20
Medicaid Expansion and the Residents of the State:
17.The Medicaid Expansion will significantly reduce the number of uninsured adultresidents, particularly in southern states, where, on average, a 50% reduction willoccur.21
18.The Medicaid Expansion will help stop the deterioration in health access thatnonelderly adults have been experiencing over the last decade. Their likelihoodof having a usual source of care and having an office visit have all declined whilethe likelihood of having an emergency room visit has increased. Nonelderlyadults were 66% more likely to report having unmet medical needs in 2010compared to 2000. Uninsured adults experienced the most dramatic declines. Bycomparison, children experienced increased coverage through Medicaid andCHIP over the decade and by the end of the decade were more likely to have ausual source of care and office visits.22
19.The Medicaid Expansion will reduce adult death rates. In states that have alreadyexpanded Medicaid, mortality rates have been reduced significantly. Death rateswere the greatest among adults between the ages of 35 and 64 years, people ofcolor, and residents of low-income counties. Adults also experienced significantreductions in delays getting health care due to cost. Comparable states that didnot expand Medicaid did not have similar results.23 A report in Tennesseeconcludes that expanding Medicaid coverage to 225,000 people would save 9lives in the state every week for the next 10 years.24
20.The Medicaid Expansion will improve the financial security of the state’sresidents. Tracking of Oregon’s Medicaid expansion to uninsured adults foundthe coverage reduces by 40% the probability that people report having to borrowmoney or skip payments on other bills because of Medicaid expenses. Itdecreases by 25% the probability that they will have unpaid medical bills sent toa collection agency.25
21.The Medicaid Expansion could reduce the growing role of health debt as a causeof personal bankruptcy. The financial security brought about by the MedicaidExpansion can lead to reductions in bankruptcies. Medical debt factors into fully62% of all bankruptcies-up from contributing to 46% of bankruptcies in 2001.26
22.The Medicaid Expansion will allow access to health services for the state’sresidents working in low pay jobs. Medicaid Expansion will provide access tohealth care for these workers. If these individuals remain uninsured, the costs oftheir illnesses and injuries will continue to be shifted onto privately insured stateresidents. As Congress noted when it enacted the ACA, this “cost shift” is nowraising family health insurance premiums, on average, by over $1,000 per year.27
23.The Medicaid Expansion will help ensure a healthier workforce for employers oflow-wage workers, including states that are employing large numbers of lowwage state employees. Improved health decreases absenteeism, which in turnincreases productivity.28
24.The Medicaid Expansion will provide coverage for working persons who losetheir jobs through no fault of their own and cannot afford to continue with theiremployer-based insurance coverage because the COBRA premiums areunaffordable.29
25.The Medicaid Expansion is critical for women. Compared with other countries(e.g. Germany, Australia, France, Canada, UK), more women in the U.S. reportthat they cannot get care because of cost. Fully 77% of uninsured women aged19-64 experienced cost-related access problems.30 In 2010, 55 percent of the 19million currently uninsured women in the U.S. had incomes low enough to qualifyfor coverage under the Medicaid Expansion.31 The Expansion will produce asignificant reduction in the number of uninsured women aged 16-64 in each ofthe 50 states.32 Expansion will offer a strong benefit package to women becauseit will include at least all of the benefits offered in the exchanges, includingmaternity and preventive services and family planning benefits.3326.The Medicaid Expansion will avoid discrimination against people with mentalhealth disabilities. When it enacted the Expansion, Congress included a provisionthat requires newly eligible individuals to receive mental health and substanceuse services at parity with other benefits.34
27.The Medicaid Expansion will help individuals with mental illness. Approximatelyone in six currently uninsured adults with income below 133% of poverty has asevere mental illness. Many others have less serious mental health conditions.35
28.The Medicaid Expansion will help homeless individuals. Half of the newly eligibleindividuals have incomes at 50% or less of the poverty line. Many of these verylow income people are homeless, and approximately ¼ of them have a seriousmental illness.36 Medicaid Expansion will mean more comprehensive care forthese individuals, allowing them to obtain chronic care management andpreventive services. Medicaid will allow the state to leverage numerous serviceoptions, such as health homes, to provide these new beneficiaries with caremanagement services linked to supportive housing.37
29.The Medicaid Expansion will help the LGBT community. Unemployment andpoverty are higher for LGBT individuals than for the general U.S. population (anestimated 14% of LGBT individuals earn less than $10,000 per year, comparedto 6% of the general population).38 As a result, a significant proportion of LGBTadults will be likely benefit from the Medicaid Expansion.
30.The Medicaid Expansion will link adults with chronic and disabling conditions tohealth care, including individuals who do not qualify for Medicare because of thatprogram’s two-year disability waiting period.39
31.Medicaid Expansion will allow access to health services for low-income Veterans, covering about 650,000 of the 1.3 million currently uninsured Vets. Texas, Floridaand California have the most uninsured veterans, with the highest number inTexas.40
32.The Medicaid Expansion, while targeted to adults, will actually help children. Inthe typical state, parents lose eligibility for Medicaid when their incomes reachjust 63% of the federal poverty line (approximately $12,000 for a family of three in2012). Medicaid Expansion will increase coverage for parents; thus, their healthstatus is expected to improve. When parents and caretakers are insured, theirchildren are more likely to be insured and to make more effective use of theircoverage. Coverage of parents also improves continuity of children’s coverageand reduces the likelihood of breaks in coverage.41 Children coming ontoMedicaid will be eligible for the program’s tailored child health benefit package,Early and Periodic Screening, Diagnosis and Treatment.42
33.The Medicaid Expansion will ensure that low-income parents are not punishedwhen they move more fully into the workforce. By contrast, in states that do notexpand, low-income parents may avoid increasing their work time because theyneed to maintain Medicaid coverage for their children.
34.The Medicaid Expansion will increase access to and use of health care by peopleof color. If implemented as written, the ACA is expected to cover 32 millionAmericans. Half of the 32 million will come into the health care system throughMedicaid, and three out of four of those individuals are people of color.43
35.The Medicaid Expansion will reduce healthcare costs by reducing healthdisparities. Between 2003 and 2006, more than $200 billion could have beensaved in direct medical care expenditures if racial and ethnic health disparitiesdid not exist. Since the lack of insurance is a contributing factor causing healthcare disparities, expanding Medicaid to provide insurance can save money.
36.The Medicaid Expansion will help slow the spread of HIV/AIDS by allowingindividuals to obtain testing and initiate treatment sooner, which can help preventthe transmission of HIV. Currently, nearly 30% of people with HIV are uninsured,and up to 59% are not in regular care.44
Existing programs for low-incomepeople with HIV/AIDS, while effective, have been increasingly strained as theirbudgets decrease while demand grows. For example, nine states currently havewaiting lists for joining an AIDS Drug Assistance Program (ADAPs). Most lowincome people living with HIV have to wait until the onset of a life-threateningopportunistic infection to qualify for Medicaid on the basis of disability. ExpandingMedicaid to individuals living with HIV, but who have not yet progressed to AIDS,will not only keep those individuals healthier longer, but will help reduce thenumber of new infections in the future.
37.The Medicaid Expansion will ensure that 11.5 million people—the poorest of thepoor—are not left out in the cold. Under the ACA, individuals with incomes below100% of the federal poverty line will not be able to obtain premium tax support forinsurance products available through the exchange.45 These individuals are likelyto remain uninsured if states do not expand Medicaid.46
38.The Medicaid Expansion will provide tailored coverage for lower-income people,including coverage that is particularly relevant to adults and couple, such asfamily planning services and supplies, and to individuals with chronic conditions,such as prescriptions and home health care.47
39.The Medicaid Expansion will ensure that enrollees help pay for their health carewhile maintaining affordability, by allowing nominal copayments for individualswith incomes below the poverty line while capping cost-sharing at five percent ofmonthly income.48
40.The Medicaid Expansion means jobs. The Expansion would bring over 7500 jobsto Tennessee in 2014 alone;
49 in Maryland, 9,122 jobs in FY 2014 alone (andnearly 27,000 jobs in FY 2020).50Following the increase in the federal Medicaidmatching rate in the American Recovery and Reinvestment Act, one estimatefrom Illinois found the Medicaid program supported as many as 385,742 jobs andgenerated wages as high as $15.8 billion during FY 2009 alone.51Medicaid Expansion and Efficiency and Fairness:
41.The Medicaid Expansion is an efficient way to cover this group of low-incomeindividuals. The Expansion merely requires addition of a new coverage group toMedicaid’s existing market-based benchmark coverage options. It does notrequire a new insurance program to be designed and a new bureaucracy to becreated. Addition of this population group will increase the bargaining power ofthe state with health plans and providers.
42.The Medicaid Expansion will extend a highly successful health insuranceprogram that every state has aggressively implemented over the years. Everystate has extended eligibility and/or services beyond the minimum coveragerequirements of the federal law. At this point, more than 60% of current Medicaidfunding covers optional population groups and services that no state is requiredto cover. In some states, the uptake of optional spending has been particularlydramatic, for example: 76.5% of expenditures in North Dakota are attributable tooptional spending; 74.7%, in Ohio; 74% in Wisconsin; 69.4% in Iowa.52
43.Medicaid is efficient. The per enrollee cost growth in Medicaid (6.1%) is lowerthan the per enrollee cost growth in comparable coverage under Medicare(6.9%), private health insurance (10.6%), and monthly premiums for employersponsored coverage (12.6%).53
44.The Medicaid Expansion and ACA will produce cost savings to states even asindividuals who are currently eligible but not enrolled in Medicaid come forward toenroll. Some states are concerned that the federal government will not really bepaying the entire bill in the first three years because individuals who are alreadyeligible for Medicaid will take advantage of the coverage “welcome mat” and“come out of the woodwork” to enroll. The states will receive their regular federalmatching funding for these already-eligible individuals. The estimates of statecosts (see #1 above) already include the costs associated with these potentialnew enrollees who are currently eligible. Equally important, the welcome mateffect will occur whether or not the state implements the Expansion. Beginning in2014, the opportunity for uninsured people to purchase health insurance withfederal subsidies will drive adults to insurance exchanges to obtain the healthinsurance, and upon arrival, their eligibility for Medicaid will automatically bedetermined—whether or not the state has expanded Medicaid.
45.The Medicaid Expansion represents fiscal responsibility and shared responsibilitybetween state and federal government. It will be more efficient for all of thefederal taxpayers who live in the state if individuals between 100-133% of thepoverty line are covered through Medicaid rather than the exchange. TheCongressional Budget Office has determined that the per capita cost of coveringthis population in the exchange will be $5,926 in 2019, as compared with $1,826through Medicaid Expansion.54 Using these numbers, a state leaving the 100-133% group to exchange coverage instead of a Medicaid Expansion wouldeffectively be arguing that the Federal government should pay $5,926 perperson, to save the state from paying $182.60 – the state’s 10% share of the$1,826 Medicaid cost. That leaves the government paying $5,926 instead of$1,643.40 – the Federal government’s 90% share of the Medicaid cost.
46.The Medicaid Expansion will mean that states’ spending of state and federaldollars for state program upgrades will not have been wasted. Beginning in April2011, states could receive significantly enhanced federal matching funds (90%instead of the usual 50% administrative matching rate) to upgrade their eligibilitysystems and make them ready for the 2014 expansions. The majority of stateshave approved (19 states) or submitted plans (10 states) to overhaul or buildtheir systems.55 If a recipient state refusing now to implement the Expansion, itwill have made an inefficient use of taxpayer funds.
47.The Medicaid Expansion merely echoes what a number of states had alreadyobtained Medicaid funding to do. States have already obtained approval from thefederal government to expand their Medicaid programs to uninsured adults—atthe current, rather than Expansion, federal matching rates. By 2008, 18 stateshad already received federal permission to extend this coverage, includingArizona, Idaho, Indiana, Maine, Michigan, Tennessee and Utah.56
48.Successes in the states illustrate the value of the Medicaid Expansion. Thesuccess of health reform in Massachusetts demonstrates that making health carecoverage available for most everyone, as would be accomplished by fullimplementation of the ACA—i.e. with the Medicaid Expansion—is the key tosuccessful reform. The Commonwealth Care program provides health careinsurance without premiums to all adults up to 150% of the poverty level.Combined with other aspects of health reform in Massachusetts, this hasresulted in 439,000 more Massachusetts residents having health care coveragecompared to before reform, with 98.1 % of residents now having coverage, thehighest rate in the country.57Medicaid Expansion and the Law:
49.State law may require the State to implement the Medicaid Expansion. Forexample, an Arizona law requires the Director of the State Medicaid program toensure that sufficient funds are available to provide Medicaid benefits to “allpersons” whose incomes are at or below the federal poverty, to be supplemented“as necessary, by any other available sources including … federal monies.”58 AnAlaska law says that “[a]ll residents of the state for whom the Social Security Actrequires Medicaid coverage are eligible to receive medical assistance” underTitle XIX of the Social Security Act.59
50.It is the law. While the Supreme Court found that a state could not be “coerced”into implementing the Expansion, its full remedy was to “limit[] the financialpressure the Secretary may apply to induce States to accept the terms of theMedicaid Expansion.”60 Thus, the Expansion population is still listed in theMedicaid Act as a group that the state “must” cover.61
- 1 January Angeles, Center on Budget and Policy Priorities, How Health Reform’s Medicaid Expansion will
Impact State Budgets (July 12, 2012) (discussing CBO estimates). - 2 The Lewin Group, a frequent consultant to state Medicaid programs, estimates savings of $101 billion.
See The Lewin Group, Patient Protection and Affordable Care Act (PPACA): Long Term Costs for
Governments, Employers, Families and Providers (June 8, 2010) (Working Paper #11); see also Matthew
Buettgens et al., Robert Wood Johnson Found. & Urban Institute, Consider Savings as well as Costs:
State Governments Would Spend at Least $90 Billion Less with the ACA than Without It from 2014 to
2019 (July 2011) (estimating total state savings from the ACA at $92-$129 billion). - 3 Annie Lowrey, N.Y. Times, How Much Would the Medicaid Expansion Cost Your State? (July 2, 2012)
(expressed as a percentage of 2011 GDP). - 4 Matthew Buettgens et al., Robert Wood Johnson Found. & Urban Institute, Consider Savings as Well as
Costs (July 2011) (citing the work of Hadley and colleagues for state and local spending on
uncompensated care). - 5 National Ass’n of State Mental Health Program Directors Research Inst., Inc., State Mental Health
Agency Revenues and Expenditures for Mental Health Services (Aug. 22, 2011). - 6 Matthew Buettgens et al., The Robert Wood Johnson Found & Urban Inst., Consider Savings as Well as
Costs (July 2011). - 7 For conditions and limits on this funding, see 42 U.S.C. § 1396b(w); 42 C.F.R. § 433.68.
- 8 Matthew Buettgens et al., The Robert Wood Johnson Found. & Urban Inst., Churning Under the ACA
and State Policy Options for Mitigation (June 2012). - 9 The Commonwealth Fund, Laura Summer & Cindy Mann, Georgetown Univ. Health Policy Instit.,
Instability of Public Health Insurance Coverage for Children and Their Families: Causes, Consequences,
and Remedies (2006). - 10 See 42 U.S.C. § 241 et seq. (establishing provisions to improve quality and efficiency of health care).
- 11 Kaiser Comm’n on Medicaid & the Uninsured, How is the Affordable Care Act Leading to Changes in
Medicaid Today? State Adoption of Five New Options (May 2012). - 12 Tara Lachapelle and Alex Nussbaum, Bloomberg News, Medicaid Insurers Turn into Targets on
Amerigroup Deal: Real M&A (Insurance Networking News, July 12, 2012); Bruce Japsen, Forbes, Why
Wellpoint’s Medicaid Play is Smarter than Rick Scott’s (July 10, 2012). - 13 See Univ. of Arkansas Sam M. Walton College of Business, The Economic Impact of Medicaid
Spending in Arkansas (May 2010); Christopher Dumas, PhD, et al., The Economic Impacts of Medicaid
in North Carolina, 69 N.C. Med. J. 78 (Mar./Apr. 2008). See also Kaiser Family Found., The Role of
Medicaid in State Economies: A Look at the Research (Jan. 2009). - 14 Andrea Kovach, Sargent Shriver National Center on Poverty Law, Expanding Medicaid: The Choice is
Clear (Shriver Brief July 10, 2012). - 15 John Lyon, Ark. News Bureau, Update DHHS: Savings to state would exceed Medicaid expansion
costs (July 17, 2012) (also attributing saving to the increased federal funding and reduction in the amount
the state spends on uncompensated care). - 16 Corey Davis, National Health Law Program, Q&A Disproportionate Share Hospitals and the ACA (June
2012). - 17 Anna Somers et al., Center for Studying Health System Change, Dispelling Myths About Emergency
Department Use: Majority of Medicaid Visits Are for Urgent or More Serious Symptoms (Brief No. 23 July
2012). - 18 Renee Y. Hsia, MD, Factors Associated With Closures of Emergency Departments in the United States
305 J. Am. Med. Ass’n 1978 (May 18, 2011). - 19 42 U.S.C. § 1395kkk.
- 20 Katherine J. Hayes, JD. et al., George Washington Univ. School of Public Health & Health Servs., How
the Supreme Court’s Medicaid Decision May Affect Health Centers: An Early Estimate (July 19, 2012). - 21 Kaiser Comm’n on Medicaid & the Uninsured, Medicaid Coverage and Spending in Health Reform:
National and State-by-State Results for Adults with Incomes at or Below 133% FPL (May 2010). See also
Center for Health Care Strategies, Planning for Medicaid Expansion: An Online ToolKit (July 2012), at
http://www.chcs.org. - 22 Genevieve M. Kenney et al., A Decade of Health Care Access Declines for Adults Holds Implications
for Changes in the Affordable Care Act, 31 Health Affairs 899 (May 2012). - 23 Benjamin D. Sommers, M.D., Ph.D. et al., Mortality and Access to Care Among Adults After Medicaid
Expansions, N. ENG. J. MED. (published on line July 25, 2012). - 24 Governor’s Communications Office, Daily News Clips at 12, Guest columnists: TennCare expansion is
worth costs (Tennessean) (July 26, 2012). - 25 Katherine Baicker, PhD, & Amy Finkelstein, PhD, The Effects of Medicaid Coverage-Learning from the
Oregon Experiment, 365 New Eng. J. Med. 683 (Aug. 25, 2011). - 26 David Himmelstein et al., Medical Bankruptcy in the United States, 2007: Results of a National Study,
122 J. of Am. Med. 741 (Aug. 2009). - 27 See 42 U.S.C. § 18091(2)(F).
- 28 Univ. of Arkansas Sam M. Walton College of Business, The Economic Impact of Medicaid Spending in
Arkansas (May 2010) (citing Karasek & Thoerell (1999) and Marslen & Moriconi (2009)). - 29 42 U.S.C. §§ 1161(a), 1162(3) (payment cannot exceed 102% of premium cost).
- 30 Ruth Robertson et al., Commonwealth Fund, Oceans Apart: The Higher Health Costs of Women in the
U.S. Compared to Other Nations, and How Reform Is Helping at Ex. 4 (July 2012). - 31 Kaiser Fam. Found., Impact of Health Reform on Women’s Access to Coverage and Care (Apr. 2012).
- 32 Ruth Robertson et al., Commonwealth Fund, Oceans Apart: The Higher Health Costs of Women in the
U.S. Compared to Other Nations, and How Reform Is Helping at Ex. 2 (July 2012). - 33 42 U.S.C. §§ 1396u-7(a)(2)(B), 1396u-7(b)(5), 1396u-7(b)(7).
- 34 See 42 U.S.C. § 1396u-7(b)(6).
- 35 Judge David L. Bazelon Center for Mental Health Law, Take Advantage of New Opportunities to
Expand Medicaid Under the Affordable Care Act (July 2012). - 36 Judge David L. Bazelon Center for Mental Health Law, Take Advantage of New Opportunities to
Expand Medicaid Under the Affordable Care Act (July 2012). - 37 Michael Nardone e t al., Center for Health Care Strategies, Medicaid-Financed Services in Supportive
Housing for
High-Need Homeless Beneficiaries: The Business Case(June 2012). - 38 American Psychological Ass’n, Lesbian, Gay, Bisexual, and Transgender Persons & Socioeconomic
Status, at http://www.apa.org/pi/ses/resources/publications/factsheet-lgbt.aspx (accessed July 31, 2012). - 39 Judith Solomon, Center on Budget and Policy Priorities, Medicaid Coverage for People with Disabilities
(July 29, 2010). - 40 Urban Institute, Uninsured Veterans and Family Members: Who are They and Where do They Live?
(May 2012). - 41 Martha Heberlein et al, Georgetown Univ. Center for Children and Families, Medicaid Coverage for
Parents under the Affordable Care Act (June 2012). - 42 42 U.S.C. §§ 1396a(a)(10)(A), 1396a(a)(43), 1396d(a)(4)(B), 1396d(r)(5), 1396u-7(a).
- 43 Imara Jones, How the Supreme Court’s “Obamacare” Ruling May Lock in Racial Inequality, Colorlines
News for Acton, June 29, 2012. - 44 Scott M. Hammer, MD, Antiretroviral Treatment as Prevention, 365 New Eng. J. Med 561 (Aug. 11,
2011). - 45 See 26 U.S.C. §§ 36B(a) & (c)(1)(A).
- 46 Genevieve M. Kenny et al., Urban Institute, Opting Out of the Medicaid Expansion Under the ACA: How
Many Uninsured Adults Would Not Be Eligible for Medicaid? (July 5, 2012). - 47 See 42 U.S.C. §§ 1396a(a)(10)(A)(i); 1396d(a).
- 48 See 42 U.S.C. §§ 1396o, 1396o-1.
- 49 Guest Column, Tennessee Needs the Medicaid Expansion, OakRidger.com (July 3, 2012) (citing study
by Univ. of Memphis Sparks Center for Business & Economic Research). - 50 S.H. Kakhraei, The Hilltop Instit., Maryland Health Care Reform Simulation Model: Detailed Analysis
and Methodology (July 2012). - 51 Andrea Kovach, Sargent Shriver National Center on Poverty Law, Expanding Medicaid: The Choice is
Clear (Shriver Brief July 10, 2012). - 52 Kaiser Family Found., Medicaid Enrollment and Expenditures by Federal Core Requirements and State
Options (Jan. 2012 update). - 53 Kaiser Family Found., Ten Myths About Medicaid (# 7306).
- 54 Sara Rosenbaum, Medicaid and National Health Care Reform, 361 New Eng. J. Med. 2009, 2011
(2009). - 55 Kaiser Family Found., How is the Affordable Care Act Leading to Changes in Medicaid Today? State
Adoption of Five New Options (May 2012). - 56 National Academy for State Health Policy, State Efforts to Cover Low-Income Adults Without Children
(Sept. 2008). - 57 Blue Cross Blue Shield Foundation, Health Reform in Massachusetts – Assessing the Results (May
2012). - 58 Ariz. Rev. Stat. § 2901.01(B) (enacted after the people passed Proposition 204).
- 59 Alaska Stat. § 47.07.020.
- 60 Nat. Fed. of Indep. Bus. v. Sebelius, 132 S.Ct. 2566, 2608 (2012).
- 61 See 42 U.S.C. § 1396a(a)(10)(A)(i)(VIII).