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Governors’ Proposed Budgets for FY 2019: Focus on Medicaid and Other Health Priorities

Executive Summary
  1. States that do not operate on the July 1 through June 30 budget cycle include Alabama, DC, and Michigan (October 1 – September 30), New York (April 1 – March 31), and Texas (September 1 – August 31).

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  2. The 39 proposed state budgets reviewed include proposed supplemental changes to the 2019 budgets for AR, CT, HI, MN, NE, and WA.

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  3. Five states (DC, MT, NV, NC, and TX) did not have proposed budgets or state of the state speeches available for review. In three states (KS, NJ, and VA), legislative addresses by incoming governors were reviewed rather than the state of the state addresses of outgoing governors. See Appendix Table 2 for more detail.

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  4. The expansion question has stalled Virginia’s budget negotiations and prompted the governor to call a special session in April to resolve differences between the Senate- and House-passed budget proposals and come to final agreement (the House’s plan includes expansion while the Senate’s plan does not).

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  5. In late March 2018, the Utah legislature passed and Governor Herbert signed a bill directing the state to seek federal approval to expand Medicaid to 100% of the FPL using the ACA enhanced federal match rate (typically only available to states that expand to 138% FPL) and add a work requirement for that newly eligible population (Utah has already submitted a separate work requirement request to CMS that would apply to some of their existing Medicaid populations).

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Issue Brief
  1. Centers Medicare and Medicaid Services. National Health Expenditure Projections 2017 – 2026 (Washington, DC: Centers for Medicare and Medicaid Services, February 16, 2018). https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html.

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  2. Kaiser Family Foundation estimates based on the National Association of State Budget Officers’ November 2017 State Expenditure Report.

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  3. State Expenditure Report, Overview: Fiscal 2015-2017, National Association of State Budget Officers, November 2017, https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/State_Expenditure_Report__Fiscal_2015-2017_-S.pdf.

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  4. Maine, which is not included in this count of 32 states, adopted the Medicaid expansion through a ballot initiative in November 2017 but has not yet implemented the expansion.

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  5. Summary: Fall 2017 Fiscal Survey of the States, National Association of State Budget Officers, December 14, 2017, https://www.nasbo.org/reports-data/fiscal-survey-of-states.

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  6. Public Law No. 115-97.

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  7. National Conference of State Legislatures, 2017 State & Legislative Partisan Composition, (National Conference of State Legislatures, November 10, 2017), http://www.ncsl.org/Portals/1/Documents/Elections/Legis_Control_2017_111017_1pm.pdf.

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  8. Of the 16 states with divided control, three have split legislatures. Nebraska’s legislature is unicameral and nonpartisan.

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  9. States that do not operate on the July 1 through June 30 budget cycle include Alabama, DC, and Michigan (October 1 – September 30), New York (April 1 – March 31), and Texas (September 1 – August 31).

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  10. Five states (DC, MT, NV, NC, and TX) did not have proposed budgets or state of the state speeches available for review. In three states (KS, NJ, and VA), legislative addresses by incoming governors were reviewed rather than the state of the state addresses of outgoing governors. See Appendix Table 2 for more detail.

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  11. Ibid.

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  12. “Saving Kentucky’s Pensions” website, https://pensions.ky.gov/Pages/index.aspx.

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  13. James Brooks,  New revenue forecast shrinks Alaska’s budget deficit a bit, Juneau Empire, December 15, 2017,   http://juneauempire.com/state/news/2017-12-14/new-revenue-forecast-shrinks-alaska-s-budget-deficit-bit.

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  14. “Executive Budget, Fiscal Year 2018-2019,” Presentation to the Joint Legislative Committee on the Budget, January 22,  2018, http://www.doa.la.gov/opb/pub/FY19/Executive_Budget_FY18_Presentation.pdf.

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  15. Jacob McCleland, Fallin Underscores Urgency To Deal With Budget Crisis In Her Final State Of The State Address, February 5, 2018, http://kgou.org/post/fallin-underscores-urgency-deal-budget-crisis-her-final-state-state-address.

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  16. Governor Ducey State of the State Address, January 9, 2018. Accessed at https://azgovernor.gov/governor/news/2018/01/arizona-state-state-2018.

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  17. Governor Holcomb State of the State Address, January 9, 2018. Accessed at http://www.in.gov/gov/2972.htm.

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  18. Governor Martinez State of the State Address, January 16, 2018. Accessed at http://www.governor.state.nm.us/uploads/PressRelease/191a415014634aa89604e0b4790e4768/Governor_Susana_Martinez_Delivers_State_of_the_State_Address_5.pdf.

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  19. Governor Raimondo State of the State Address, January 16, 2018. Accessed at http://www.governor.ri.gov/newsroom/speeches/2018/state-of-the-state.php.

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  20. Other frequent state of the state topics included proposals to: enhance or improve public safety or criminal justice administration; address environmental or climate change concerns; promote economic development; improve state adoption and/or child welfare services; and prevent sexual harassment of state employees in the workplace. A smaller number of governors proposed efforts to: reduce homelessness or increase affordable housing; reduce gun violence; improve funding for public pensions; and raise the minimum wage or provide for paid sick leave.

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  21. In addition, Florida would reduce certain fees and expand sales tax holidays, Rhode Island and West Virginia would reduce taxes on manufacturers, Illinois and Nebraska would provide property tax relief, Idaho would reduce unemployment taxes, and Massachusetts would increase the state’s Earned Income Tax Credit.

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  22. The specific taxes to be increased were not identified in Colorado and Kentucky.

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  23. Colorado’s governor proposed a voter referendum regarding sustainable transportation funding and where it should come from and Kentucky’s governor urged the legislature to adopt genuine tax reform that would generate additional revenue for the state.

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  24. Additional states with proposed tax increases include Minnesota (repeal of 2017 tax cuts for tobacco companies, corporate property taxes, and estate taxes), New York (excise tax on vapor products, an opioid epidemic surcharge and a health care insurance windfall profit fee), Pennsylvania (new severance tax on natural gas); Rhode Island (expanded medical marijuana fees (to be generated by 12 new Compassion Centers) and increased sports betting revenue), Utah (reforms to broaden the sales tax base (e.g., to internet sales) in order to keep rates low), Washington (temporary carbon pollution tax), and Wyoming (governor urged the state’s legislature to continue looking at a lodging tax and tobacco tax that could be used for education).

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  25. John Hicks, New Federal Tax Law: Individual State Conformity Laws will Impact State Taxable Income, (National Association of State Budget Officers, January 2018), http://budgetblog.nasbo.org/budgetblogs/blogs/john-hicks/2018/01/08/new-federal-tax-law-individual-state-conformity-la

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  26. Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999–2016. NCHS Data Brief, no 294. Hyattsville, MD: National Center for Health Statistics. 2017/ CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov.

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  27. Other state examples include Colorado and Connecticut, that proposed to replace expiring Money Follows the Person federal grant funds with state funds, California proposed increased funding for its In-Home Supportive Services program, and New York proposed to expand Assisted Living services. Georgia also proposed an enhancement for nursing facility residents – an increase in the personal needs allowance.

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  28. The Louisiana governor and legislative leaders are debating whether to renew or replace over one billion dollars in temporary taxes that expire next summer, forcing Governor Edwards to propose a FY 2019 budget with massive cuts, described by the Governor as a budget “we do not support, do not endorse, and hope will never be enacted.”

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  29. Seven states (Arizona, Arkansas, Indiana, Iowa, Kentucky Michigan, and Montana) have received Section 1115 waiver approval to charge premiums or monthly contributions that are not otherwise allowed for their Medicaid expansion adults; these amounts are generally 2% of income, equivalent to what beneficiaries from 100-138% FPL would incur if they enrolled in Marketplace coverage.

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  30. Some groups and services are exempt from cost sharing, including children enrolled through mandatory eligibility pathways, emergency services, family planning services, pregnancy-related services, and preventive services for children.

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  31. Rhode Island also proposed to expand availability of its RiteShare premium assistance program for employer sponsored insurance to all populations and promote existing law to improve take-up of this option.

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  32. Dear State Medicaid Director Letter (SMD: 18-002), Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries, January 11, 2018. Accessed at https://www.medicaid.gov/federal-policy-guidance/downloads/smd18002.pdf.

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  33. MaryBeth Musumeci, Rachel Garfield, Robin Rudowitz, Medicaid and Work Requirements: New Guidance, State Waiver Details and Key Issues, Kaiser Family Foundation Issue Brief, January 2018. Accessed at https://www.kff.org/medicaid/issue-brief/medicaid-and-work-requirements-new-guidance-state-waiver-details-and-key-issues/.

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  34. In late March 2018, the Utah legislature passed and Governor Herbert signed a bill directing the state to seek federal approval to expand Medicaid to 100% of the FPL using the ACA enhanced federal match rate and add a work requirement for that newly eligible population (Utah has already submitted a separate work requirement request to CMS that would apply to some of their existing Medicaid populations).

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