THE COST OF JUST SAYING NO SHERRY GLIED WAGNER SCHOOL OF PUBLIC SERVICE NEW YORK UNIVERSITY Thanks to Stephanie Ma for research assistance and to the Commonwealth Fund for research support.
WHAT NO MEANS No new State spending for expansion population in out years (10% of expansion population cost in 2020) Less opportunity to Medicaid-ize existing state services No new Federal funds for expansion population Less multiplier impact of Federal funds
COSTS INCURRED DESPITE SAYING NO State share of cost for old eligibles due to woodwork effect Diversion of Federal taxes (general revenues) paid by state taxpayers toward Federal share of expansion in expansion states
STATE COSTS OF EXPANDING MEDICAID
DIRECT STATE COSTS OF EXPANSION AS SHARE OF STATE BUDGETS, 2022 3.5 3 2.5 2 Percent (%) 1.5 1 0.5 0-0.5-1 -1.5 All expansion All undecided Alabama Alaska Florida Georgia Idaho Kansas Louisiana Maine Mississippi Missouri Nebraska North Carolina Oklahoma South Carolina South Dakota Texas Utah Virginia Wisconsin Wyoming Holahan et al.
COSTS TO STATE BUDGETS NET OF UNCOMPENSATED CARE, 2022 3 2.5 2 1.5 Percent(%) 1 0.5 0-0.5-1 -1.5 All expansion All undecided Alabama Alaska Florida Georgia Idaho Kansas Louisiana Maine Mississippi Missouri Nebraska North Carolina Oklahoma South Carolina South Dakota Texas Utah Virginia Wisconsin Wyoming Holahan et al.
COMPARED TO WHAT?
PER CAPITA FEDERAL FUNDS FOREGONE, 2016 Per Capita Federal Funds * Individual data labels: Aggregate Federal Funds in millions Based on Holahan et al.
PER CAPITA FEDERAL FUNDS FOREGONE, 2022 800 2,121 700 60,645 6,571 2,102 213 5,781 Per Capita Federal Funds 600 500 400 300 9,645 4,918 477 767 2,312 457 2,590 444 1,252 2,312 307 9,582 784 2,144 1,753 198 200 100 0 All expansion All undecided Alabama Alaska Florida Georgia Idaho Kansas Louisiana Maine Mississippi Missouri Nebraska North Carolina Oklahoma South Carolina South Dakota Texas Utah Virginia Wisconsin Wyoming * Individual data labels: Aggregate Federal Funds in millions Based on Holahan et al.
NET STATE COSTS VS. FEDERAL FUNDS FOREGONE / STATE BUDGETS, 2022 25 24 23 Direct Costs 22 21 Federal Funds 20 19 18 17 16 Percent (%) 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0-1 -2-3 All expansion All undecided Alabama Alaska Florida Georgia Idaho Kansas Louisiana Maine Mississippi Missouri Nebraska North Carolina Oklahoma South Carolina South Dakota Texas Utah Virginia Wisconsin Wyoming
PER CAPITA STATE DIRECT COSTS / PRIVATE INCENTIVES, 2022 1200 1000 ACA Costs Private Incentive Costs 800 600 Per Capita 400 200 0-200 -400-600 All expansion All undecided Alabama Alaska Florida Georgia Idaho Kansas Louisiana Maine Mississippi Missouri Nebraska North Carolina Oklahoma South Carolina South Dakota Texas Utah Virginia Wisconsin Wyoming Glied and Ma
PER CAPITA FEDERAL FUNDS FOREGONE/ HIGHWAY AND DEFENSE FUNDS, 2022 2500 2250 ACA Funds Highway Funds Defense Funds 2000 1750 1500 1250 1000 750 500 250 0 All expansion All undecided Alabama Alaska Florida Georgia Idaho Kansas Louisiana Maine Mississippi Missouri Nebraska North Carolina Oklahoma South Carolina South Dakota Texas Utah Virginia Wisconsin Wyoming Per Capita Glied and Ma
COSTS INCURRED DESPITE SAYING NO
WOODWORK EFFECTS NEW MEDICAID ENROLLMENT ON WEBSITES THROUGH DECEMBER 2013 40000 35000 Number of Medicaid Enrollees 30000 25000 20000 15000 10000 5000 0 All expansion in Fed Ex All expansion with State Ex All undecided states Alabama Alaska Florida Georgia Idaho Kansas Louisiana Maine Mississippi Missouri Nebraska North Carolina Oklahoma South Carolina South Dakota Texas Utah Virginia Wisconsin Wyoming ASPE
NET FEDERAL REVENUE FLOWS IF STATES DON T EXPAND, 2022 0-1000 -2000-3000 $ (in millions) -4000-5000 -6000-7000 -8000-9000 -10000 All expansion All undecided Alabama Alaska Florida Georgia Idaho Kansas Louisiana Maine Mississippi Missouri Nebraska North Carolina Oklahoma South Carolina South Dakota Texas Utah Virginia Wisconsin Wyoming Glied and Ma
WHO GAINS AND LOSES FROM NON- EXPANSION? LOSERS GAINERS Low income non-expansion state residents Non-expansion state residents who own or are employed by businesses associated with health care (and multipliers) State residents who own or are employed by businesses used by beneficiaries (and multipliers) Taxpayers in expansion states Non-expansion state residents who pay high state taxes but do not benefit from state economic growth
FURTHER INFORMATION Medicaid brief http://www.commonwealthfund.org/publications/issue-briefs/ 2013/Dec/Federal-Funds-Medicaid-Expansion.aspx Holahan brief http://kaiserfamilyfoundation.files.wordpress.com/ 2013/01/8384.pdf ASPE expansion data http://aspe.hhs.gov/health/reports/2013/ marketplaceenrollment/dec2013/ib_2013dec_enrollment.pdf Sherry.glied@nyu.edu