Putting Medicaid in the Larger Budget Context: An In-Depth Look at Four States in FY 2016 and FY 2017

Introduction

Medicaid has long-played an important role in the U.S. healthcare system, accounting for one in every six dollars of all U.S. health care spending while providing health and long-term services and supports coverage to millions of low-income Americans.¹ Medicaid also plays an important role in states budgets as both an expenditure item and the largest source of federal revenue for states.

Since 2014, an improving economy and the implementation of the Affordable Care Act (ACA) have been the primary drivers of Medicaid enrollment and spending trends. Medicaid enrollment and spending peaked in FY 2015, the full state fiscal year for states implementing the ACA, but growth slowed significantly in FY 2016 and FY 2017. Across the country, states remain focused on the ACA, but also on other priorities such as payment and delivery system initiatives designed to control costs and achieve better health outcomes. These policy priorities are playing out in the context of broader state budgets and an economy that varies across states, with some states experiencing steady economic growth and others facing declines in state revenues.

This report provides an in-depth examination of Medicaid program changes in the larger context of state budgets in four states:

• Maryland
• Montana
• New York
• Oklahoma

These case studies build on findings from the 16^th annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by the Kaiser Commission on Medicaid and the Uninsured (KCMU) and Health Management Associates (HMA). Additional research on budget activity, economic conditions, and other relevant health policy activity was collected to supplement survey responses.

Issue Brief

Maryland

Economic and Budget Outlook

Economy and State Revenues

Maryland’s economy has shown signs of continued recovery from the Great Recession. The state’s Gross Domestic Product (GDP) in 2014 was $350.3 billion, ranking 15th in the United States. Finance, insurance, real estate, rental, and leasing was the largest industry in Maryland, followed by government; professional and business services; and educational services, healthcare, and social assistance.¹ The state had an unemployment rate of 4.3 percent in July 2016, down from 5.1 percent in July 2015 and below the U.S. average of 4.9 percent.² The state experienced revenue growth of 3.9 percent in FY 2016 and projects 2.7 percent growth in FY 2017. This includes a projected 5.2 percent increase in revenues from the individual income tax in FY 2017 as well as a 2.1 percent projected increase in corporate income tax and sales tax revenue.³

State Budget

Governor Larry Hogan’s budget proposal of $42.3 billion for FY 2017 focused strongly on assuring that the state’s economic recovery stayed on track. Maryland faced $5.1 billion in accumulated structural deficit when the Governor took office in 2015, and addressing this deficit has been a primary focus for the Hogan Administration.⁴

The FY 2017 budget proposal included a tax and fee relief plan that would reduce general fund revenues in FY 2017 by $23.2 million. The budget proposal also included a 7 percent increase in state support for Medicaid. Even with these changes, the Governor’s proposed budget projected a surplus of $449 million for FY 2017 and an ending Rainy Day Fund balance of $1.1 billion. The Governor’s priorities included education, addressing transportation infrastructure, and spurring continued economic development. The budget as enacted included state general funds to offset the reduction in federal matching rate (from 100 percent to 95 percent FMAP) for the Medicaid adult expansion population, and reflected a 5.9 percent projected growth in total Medicaid expenditures.⁵

Update on the Affordable Care Act

Maryland Medicaid covers almost 1.3 million residents, including 258,000 adults who gained coverage as a result of Maryland expanding Medicaid eligibility under the Affordable Care Act. Like other states, Maryland saw higher growth than expected in the newly eligible adult population and some corresponding reduction in the rate of enrollment for other population groups, suggesting that some individuals were able to enroll through the income-only based category rather than depend on more complex eligibility under the aged, blind or disabled or other categories. The state is still evaluating the cost and utilization profile for the expansion adult population, which initially had a lower cost experience than the state expected.

Maryland experienced a slowing of enrollment during FY 2015 and FY 2016 due to resumption of eligibility redeterminations which had been temporarily delayed. Growth in the expansion population rebounded later in the fiscal year, and the state projects an enrollment increase of 17 percent in FY 2017 for this eligibility group.

Maryland implemented several new service options or grant programs under the ACA that target home or community based services for individuals with chronic or disabling conditions. In FY 2014, the state introduced health homes to support integration of physical and behavioral health care services for an estimated 15,000 individuals with behavioral health needs who are at high risk of additional chronic conditions. Health home providers can be psychiatric rehabilitation programs, mobile treatment service providers, or opioid treatment programs.⁶

The state also adopted the Section 1915(k) Community First Choice (CFC) benefit in FY 2014 to provide personal assistance services, accessibility adaptations, transition services and other supports for Medicaid beneficiaries requiring an institutional level of care. CFC services are provided in an individual’s home, including in assisted living settings. In FY 2015, the state implemented a new Section 1915(i) HCBS state plan option for children with Serious Emotional Disturbances (SED). This state plan option was implemented to sustain and refine the services that Maryland had offered under the Residential Treatment Center Waiver (RTCW).^7,8

In addition, Maryland received a Balancing Incentive Program (BIP) grant, which provided an enhanced 2 percent rate of federal matching funds for all HCBS expenditures through September 30, 2015 to support state efforts to achieve a target that at least 50 percent of LTSS funds be spent on HCBS. By the second quarter of Federal FY 2016, Maryland reported that 60.5 percent of the state’s LTSS were for HCBS, a significant increase over the pre-BIP rate of 36.8 percent reported in Federal FY 2009.⁹ Other elements of BIP required development of a functional assessment for use in the state’s Medicaid LTSS programs, adoption of conflict-free case management in LTSS, and a No Wrong Door approach to providing information and entry for state residents seeking LTSS.

Health System Reform in Maryland

For many years, Maryland has pursued health system reform for Medicaid and other health care payers through a combination of two large federal waiver strategies.  Both waiver programs are undergoing further reforms to support achievement of improved health outcomes and reduced rates of cost growth.

Section 1115 HealthChoice Waiver

Maryland Medicaid has operated HealthChoice, a statewide mandatory managed care program for Medicaid enrollees, since 1997 under a Section 1115 demonstration waiver.¹⁰ The HealthChoice program aims to provide patient-focused, coordinated care through medical homes. Over 80 percent of Maryland’s Medicaid beneficiaries are served through MCOs, including almost 97 percent of children and 94 percent of the expansion adult population. Enrollment in HealthChoice for physical health care services is mandatory for all children and non-Medicare eligible adults, including persons with intellectual and developmental disabilities, most adults with physical disabilities, most children with special health care needs and persons with a serious mental illness. (Note: Specialty mental health and substance use services are carved out of HealthChoice MCOs and managed by a single Administrative Services Organization. Long-term services and supports are provided in a fee-for-service arrangement outside the HealthChoice arrangement.)

In June 2016, Maryland filed a HealthChoice waiver renewal application with CMS (to cover January 2017-December 2019). Under a renewed waiver, Maryland is proposing a variety of system reforms designed to improve outcomes for covered individuals. These include but are not limited to:¹¹

• Residential treatment for adults with substance use disorders. As one part of a comprehensive approach to solving Maryland’s substance abuse epidemic, Maryland proposes to include coverage of residential treatment in facilities that would otherwise not qualify for Medicaid reimbursement under the federal financing exclusion for individuals in Institutions for Mental Disease.¹²
• Presumptive eligibility for individuals with criminal justice involvement to better connect individuals to health coverage at release and bolster efforts to prevent recidivism.
• Dental coverage for former foster youth up to age 26. Under current rules, EPSDT dental benefits end at age 21.

The renewal proposal also includes pilots to allow local entities to receive federal matching funds for care coordination and other services that address key social determinants of health. These include:

• Limited housing support services for up to 300 Medicaid beneficiaries statewide who are at risk of becoming or are currently homeless.
• Evidence-based home visiting for high-risk pregnant women and children.

CMMI Approved Maryland All-Payer Model

Maryland has operated an all-payer hospital payment system under its Health Services Cost Review Commission (HSCRC) since 1977, and is now the only all-payer hospital payment system in the country. This all-payer system has operated under a Medicare waiver, codified in Section 1814(b) of the Social Security Act, that exempted Maryland from the Medicare Inpatient Prospective Payment System and Outpatient Prospective Payment System and allowed Maryland to continue its state-developed approach to hospital reimbursement.¹³ In 2014, Maryland received a new waiver from the Center for Medicare and Medicaid Innovation (CMMI) that authorized the HSCRC to pursue more significant reforms to support state goals for health system improvement.¹⁴

Under the five-year waiver, Maryland is authorized to require every hospital payer, whether Medicare, Medicaid, a commercial payer, or an individual consumer, to pay the same charge for the same service. In addition, Maryland will shift all of its hospital revenue over the five-year performance period into global payment models. The state will limit all-payer per capita hospital growth, including inpatient and outpatient care, to 3.58 percent and the annual Medicare per capita hospital cost growth to a rate lower than the national annual per capita growth rate per year for 2015-2018. Hospitals have committed to achieving significant quality improvements across all populations, including reductions in the 30-day hospital readmissions rate and hospital acquired conditions rate. Hospitals will submit annual reports of various population health measures.¹⁵ Maryland is responsible for submitting a plan for the progression of the All-Payer Model to the Centers of Medicare and Medicaid Services (CMS) by January 2017.

The state implemented an All Payer Claims databased (APCD) that includes enrollment, provider and claims data for Maryland residents enrolled in private insurance, Medicare or Medicaid MCOs. The APCD is a decision support tool for various state health reform partners, including the HSCRC and the Maryland Insurance Administration.¹⁶ In addition, the State’s designated Health Information Exchange (HIE), CRISP (Chesapeake Regional Information System for our Patients) allows clinical information to move electronically among disparate health information systems. The goal of HIE is to deliver the right health information to the right place at the right time – providing safer, more timely, efficient, effective, equitable, patient-centered care.

State Innovation Model

Maryland received a CMMI Round Two State Innovation Model (SIM) grant that is supporting state development of a strategy to integrate care delivery for individuals who are dually-eligible for Medicare and Medicaid. The state is engaging stakeholders to design an approach that is aligned with the All-Payer Model, will reduce service fragmentation, and will improve outcomes for individuals with complex health conditions.¹⁷ In an effort to mitigate the financial misalignment between Medicare and Medicaid, the all-payer model progression plan due at the end of 2016 to CMMI will include an implementation plan and timeline for including the duals in the future total cost of care calculations.

Addressing the Opioid Abuse Crisis

Maryland has placed a high priority on addressing the public health emergency resulting from abuse of opioid prescription drugs and heroin. In response to a dramatic increase in the number of deaths from overdose, Governor Hogan created the Opioid and Heroin Emergency Task Force (Task Force) in 2015 to engage experts and the broader public in identifying strategies to fight the problem. Under the auspices of an Inter-Agency Coordinating Council, Maryland state agencies work together to promote prevention, treatment and recovery efforts to reduce opioid overdose deaths. Strategies include identifying patterns of overdose activity through timely review and analysis of data from the Office of the Chief Medical examiner, improving access to substance use disorder treatment and recovery services, providing clinical education and training for healthcare providers, and implementing a Prescription Drug Monitoring Program. Effective October 1, 2015, physicians, advanced practice nurses, dentists and other providers with prescribing authority can prescribe Naloxone to any patient considered at risk of experiencing an opioid overdose or who is in a position to assist an individual at risk of overdose. This provision includes protections from civil lawsuits for prescribers and pharmacists who prescribe or dispense in good faith and according to statutory requirements. In addition, the law enhanced the Maryland Overdose Response Program, which trains and certifies community members in opioid overdose response with Naloxone.¹⁸

Maryland has continued to experience significant increases in heroin and opioid-related abuse; between 2014 and 2015, heroin-related fatal overdoses rose 29 percent and deaths from Fentanyl rose 83 percent¹⁹, while deaths from misuse of prescription drugs increased 6 percent. The Governor’s FY 2017 budget proposed $4.8 million in new funding to implement recommendations of the Task Force, including initiatives to enhance quality of care and expand access to treatment and support services. The Governor signed the National Governors Association (NGA) Compact to Fight Opioid Addiction in July 2016, and Maryland received a grant award in August 2016 from the U.S. Department of Health and Human Services under the Strategic Prevention Framework Partnerships for Prescription Drugs program.

The Maryland Medicaid program has established a workgroup on opioid harm reduction that includes both state staff and medical and pharmacy staff leadership from the Medicaid MCOs. This workgroup is engaged in developing a consistent set of prior authorization and step therapy strategies and is working to adopt the prescribing guidelines issued by the Centers for Disease Control, and in some cases go beyond the CDC recommendations. The state intends to expand use of prior authorization requirements for use of Fentanyl and Methadone in FFS arrangements in FY 2017 and all Fentanyl products in MCOs in FY 2017 and to add PA requirements in FY 2018 for Methadone and all long-acting opioid-based treatments, in both fee-for-service and MCO arrangements. In addition, MCO Medicaid prescribers will be required to check the Prescription Drug Monitoring Program before prescribing opioids in FY 2018. The state is implementing enhanced education efforts in both FFS and MCO arrangements in FY 2017, sending letters to patients and providers when patients are receiving high dose or other high risk combinations of drugs.

Maryland Medicaid Policy Changes FY 2016 and FY 2017

Eligibility, Application and Renewal Policies

Participating in Connecting Criminal Justice with Health Care learning collaborative to identify best practices for Maryland. Does not suspend of terminate coverage, but restricts payments to inpatient hospital stays longer than 24 hours. Requesting presumptive eligibility under Section 1115 waiver renewal (FY 2018).

Delivery System and Payment Reforms

Medicaid participation in All-Payer Claims database in FY 2016. HealthChoice Section 1115 waiver renewal filed in June 2016 proposing new initiatives, including residential treatment for substance use disorder in facilities regardless of size; local pilots to provide limited housing related services for certain individuals who are homeless or at risk of homelessness; and local pilots to provide home visiting for high risk pregnant women. (While the waiver renewal has a proposed effective date of January 1,2017; many changes are proposed to be effective July 1, 2017.)

Provider Rates and Provider Fees/Taxes

Across the board rate increases, except for nursing facilities. (2016) Rate increases for nursing facilities and hospitals; rate changes for MCOs: 5.9% in CY 2016 and 1% for CY 2017. Provider tax rate for hospitals decreased in FY 2017.

Benefits and Pharmacy

Adding Applied Behavioral Analysis services for qualified children with Autism Spectrum Disorder. (FY 2016) Proposing in Section 1115 waiver renewal to extend dental benefits to young adults aging out of the foster care system. (FY 2017) Added Physician Assistants as a new provider type. (FY 2016) The state intends to expand use of prior authorization requirements for use of Fentanyl and Methadone in FFS arrangements in FY 2017 and all Fentanyl products in MCOs in FY 2017.  The state is implementing enhanced education efforts in both FFS and MCO arrangements in FY 2017, sending letters to patients and providers when patients are receiving high dose or other high risk combinations of drugs.

Montana

Economic and Budget Outlook

Economy and State Revenues

At the beginning of 2016, economists at the University of Montana Bureau of Business and Economic Research reported on the strong performance of Montana’s economy in 2015 noting that the state reached full employment with wage growth more than twice as strong as 2014 and experienced broad growth across most industries boosting state tax revenues and wages.¹ While overall results were strongly positive, the economists also noted weaknesses in the energy, mining and agricultural sectors driven by falling prices for grains, oil and natural gas, weakened demand for coal and an associated slow-down in oil and gas-related energy activity. According to the Montana Department of Commerce, the state’s Gross Domestic Product (GDP) grew by 3.4 percent in 2014 and 2.8 percent in 2015² while the unemployment rate in July 2016 stood at 4.2 percent, below the national average rate of 4.9 percent.³

Montana’s total state General Fund (GF) revenue is heavily reliant on individual income taxes which comprise over half of total GF collections. Although oil, gas and coal revenues make up less than 3 percent of total GF revenues,⁴ oil production from the Bakken shale formation has brought a new oil boom to the state, making the price of oil an increasingly important variable impacting state revenue collections.⁵ The state experienced robust GF revenue growth of 5.9 percent in FY 2015, but revenue collections weakened in FY 2016, finishing the year $79 million (3.6%) below FY 2015 levels and $142 million (6.3%) below the budgeted amount largely driven by declining oil prices which affected revenues and corporate income taxes.⁶ GF balances were estimated to fall to $109 million by the end of FY 2017,⁷ down from $455.1 million at the end of FY 2015.⁸

State Budget

The Montana legislature meets only in odd-numbered years, when it addresses the full range of legislative issues and also must adopt a balanced biennial budget. Heading into the 2015 legislative session, Governor Bullock proposed a FY 2016-2017 budget that included a state general fund spending increase of 5.5 percent for FY 2016 and almost 3 percent for FY 2017, $300 million in public works projects statewide, and a projected FY 2017 general fund minimum ending balance of $300 million.⁹  The most contentious issue in the Governor’s proposal was the adoption of the Medicaid expansion under the Affordable Care Act (described further below).¹⁰ The biennium budget ultimately passed by the legislature included total general fund spending of $2.0 billion in FY 2016 and $2.05 billion in FY 2017, lower than the Governor’s proposal, but higher than FY 2015 spending levels.¹¹

Montana’s ACA Medicaid Expansion

In January 2015, Democratic Governor Steve Bullock unveiled proposed legislation to create the “Healthy Montana Plan.”¹² The Governor’s proposal to expand Medicaid to approximately 70,000 adults and serve them through competitive state contracts with managed care companies was modeled on the Healthy Montana Kids program, which provides coverage for children in low-income families. Republican lawmakers had narrowly defeated a similar bill at the end of the 2013 session on the grounds that the state would eventually have to cover the costs. Despite having the support of the Montana hospitals¹³ and a provision to terminate coverage if federal funding dropped below 90 percent; Republican lawmakers remained opposed and introduced a variety of alternatives to the Governor’s proposal, some that included the Medicaid expansion and others that did not (Big Sky Health¹⁴). One proposal, the Montana Healthy Family Plan, would have covered an estimated 15,000 Montanans providing Medicaid coverage on a smaller scale with the commitment of serving the “neediest among us” before considering expansion of non-disabled adults without children.¹⁵

A party-line vote (10-7) in the House Human Services Committee in favor of a “do not pass” motion, came after a marathon, six-hour hearing on the proposal, attended by scores of supporters who traveled from across the state to advocate for the measure.¹⁶ A “do not pass” vote was described as a rarely used motion that made resurrecting a bill very unlikely as a three-fifths vote of the House rather than a simple majority is needed to overturn the motion and allow the full House to consider the bill.¹⁷ Republicans held a 59-41 majority in the House. Three Republican alternatives to the Healthy Montana Plan were also voted down on the floor of the House that day. One Medicaid expansion bill survived, Senate Bill 405, the Health and Economic Livelihood Partnership (HELP) Act sponsored by Republican Senator Ed Buttrey. The HELP Act mirrored the Governor’s proposal calling for coverage of nearly 70,000 Montanans; however in an effort to obtain bi-partisan support the bill included measures intended to achieve a compromise and appeal to conservatives, most notably a jobs plan and premiums.¹⁸

Despite its bi-partisan approach, the HELP Act was subjected to numerous procedural motions to prevent a floor debate. In the House, it took nine mostly procedural floor votes before Senate Bill 405 reached its final vote for approval.¹⁹ Throughout the session, a group of Republicans joined with all Democrats to provide the majority needed to advance the bill through the process. On April 29, 2015, Governor Bullock signed the HELP Act into law.

Seven months later (on November 2, 2015) CMS approved Montana’s HELP program and 13 related state plan amendments, with coverage effective on January 1, 2016. The waiver expands coverage to approximately 70,000 parents and childless adults, aged 19 to 64 earning up to 138 percent of the federal poverty level (FPL).²⁰ With the exception of certain exempt groups of people²¹, newly eligible adults receive services through a managed fee-for-service Third Party Administrator (TPA) arrangement (described below).  The HELP Program requires monthly premiums up to 2 percent of household income for newly eligible adults from 51 to 138 percent FPL receiving services through the TPA. Beneficiaries from 101 to 138 percent FPL may be disenrolled for failing to pay premiums after notice and a 90-day grace period. Re-enrollment is required (without a new application) upon payment of arrears or when the state Department of Revenue assesses the debt against income taxes. Beneficiaries subject to premiums receive a credit toward accrued copayments up to 2 percent of income. All cost-sharing is limited to 5 percent of quarterly household income. Finally, the waiver provides all HELP Program beneficiaries (including those exempt from the TPA) with twelve months of continuous eligibility to reduce the effects of churning between Medicaid and Marketplace coverage as income fluctuates. This continuous eligibility authority granted by an 1115 waiver is unique among states seeking Medicaid expansion waivers.

The Montana HELP Act also authorized the Montana Department of Labor & Industry (DLI) to administer a workforce program, HELP-Link²², in conjunction with expanded health coverage. HELP-Link offers enrollees the opportunity to develop a customized employment plan, connect with local employers, and open access to training resources. As of June 30, 2016, 1,004 Montana HELP Plan participants have or are currently receiving workforce services from DLI through the HELP-Link program, the Workforce Innovation and Opportunity Act (WIOA) program, and the RESEA program (an Unemployment Insurance partnership program providing intensive employment services to Montanans who have recently lost a job).²³

Enrollment as of July 2016 (47,399) was nearly double Montana’s initial projection that 25,000 would enroll in the first six months. The state also reports that $5.3 million was saved by shifting 8,458 people from traditional Medicaid into the expansion.²⁴ Further, the HELP Act has also had a significant impact on the state’s insured rate. In 2013, approximately 195,000 Montanans, or 20 percent of the population, lacked health insurance. In 2015, before the Medicaid expansion took effect, an estimated 151,000 Montanans lacked health insurance (15% of the population). Under the HELP Act, the percentage of Montanans who are uninsured dropped to 7.4 percent, a 50 percent decline from 2015 to 2016.²⁵

Delivery System Reform

HELP Program Third-Party Administrator

Montana was the first state in the country to expand Medicaid using a private TPA arrangement where the TPA vendor receives an administrative fee but is not at risk for medical claims. Also, claims continue to be paid by the TPA on a fee-for-service basis. The state’s Healthy Montana Kids program, its Children’s Health Insurance Program uses a TPA model as well. Montana opted to contract with a TPA to deliver services to HELP Program enrollees using the provider network and administrative infrastructure of an insurer already providing services in the state. In order to implement the TPA and require enrollees to receive services from the TPA’s provider network, the state received approval to waive freedom of choice requirements (except family planning providers) using Section 1915(b) selective contracting authority.²⁶ To promote continuity of care between Medicaid and the Marketplace, the state chose an insurer that offered a qualified health plan on the Marketplace.

Other Medicaid Initiatives

Benefit Expansions

With the expansion of Medicaid in Montana, the Bullock Administration sought to ensure that newly eligible adults would have access to a comprehensive benefit package. One example is dental coverage, which Montana’s children, aged, blind, and disabled population had long benefited from. Newly eligible adults now have access to dental coverage of $1,125 per benefit year exclusive of diagnostic, preventive, denture and anesthesia services. In order to provide access to dental coverage for the expansion population and to maintain the unlimited benefit for the aged, blind and disabled, Montana is amending an existing Section 1115 waiver to leverage savings that have accrued under the waiver. As of May 12, 2016, less than six months into the HELP Program, 11,727 preventive dental exams had been provided.²⁷

In addition to dental services, Montana implemented changes to its behavioral health benefit to improve access to mental health and substance use disorder services. Limits on mental health therapies were removed and age limits for substance use disorder treatment were eliminated. Prior to the Medicaid expansion, substance use disorder services for the adult population were funded by the state mental health agency. Many individuals receiving these services were uninsured and therefore did not have access to a full benefit package. As a result of the Medicaid expansion and associated federal funding, these individuals now have access to a comprehensive benefit package and the state has realized savings in its state-funded mental health program.

Additional Medicaid policy actions taken in FY 2016 or planned for FY 2017 are described below.

New York

Economic and Budget Outlook

Economy and State Revenues

The State of New York has the third largest economy in the United States (behind California and Texas) with a Gross Domestic Product (GDP) of $1.4 trillion in 2015.¹ Among the various industry sectors comprising the state’s economy, the education and health care sector is now the largest (in terms of employment), has steadily grown reaching 15.2 percent of total nonfarm payroll employment in 2015. By contrast, the manufacturing sector has decreased over the last 15 years to 4.9 percent in 2015. The financial sector is also very important to the overall health of the state’s economy but was especially hard-hit by the Great Recession (2007-2010). This sector has rebounded slowly as technology, stricter regulations, and high operating costs have inhibited hiring, accounting for 7.6 percent of total nonfarm payroll employment in 2015.²

In line with the national economy, the New York economy has experienced slow and steady growth since the last recession with GDP growth of 1.2 percent in 2014³ and 1.4 percent in 2015.⁴ Employment has also steadily grown since 2010 and the unemployment rate fell to 4.7% in July 2016.⁵ In February 2016, the New York State Assembly Ways and Means Committee Economic and Revenue Report forecasted that state employment and personal income in New York would continue to grow in 2016 and 2017, but at somewhat more moderate pace.

State tax growth has been positive in recent years growing by 1.9 percent in FY 2015 and 5.1 percent in FY 2016.⁶ While growth in FY 2017 was originally forecasted at 3.3 percent, that estimate was reduced to 2.4 percent in the first quarter update issued by the Division of the Budget in August 2016.⁷ According to that report, through the first quarter of FY 2017, personal income tax collections fell $595 million below planned levels reflecting continued weak performance in the financial sector. Other taxes, however, remain on target with earlier estimates.

State Budget

Unlike most other states whose fiscal years begin on July 1, the State of New York operates on an April 1 – March 31 state fiscal year. New York’s enacted budget for FY 2017 of $96.2 billion⁸ holds state spending to a 2 percent growth rate for the sixth consecutive year,⁹ but grows school aid by $1.5 billion (6.5%)¹⁰ and includes the largest state transportation plan ($55 billion) ever approved.¹¹ The enacted budget for FY 2017 also authorizes regional, phased-in increases to the state’s minimum wage to $15 an hour and the nation’s only 12-week paid family leave program.¹²

The FY 2017 Medicaid budget growth of 3.4 percent reflects the continuation of the Medicaid spending cap (called the “Global Cap”) adopted in FY 2012 which limits year-to-year growth in the state share of Medicaid spending to the ten-year rolling average of the medical component of the Consumer Price Index (CPI).¹³ The Division of the Budget currently estimates that projected CPI reductions will reduce the Medicaid Global Cap to 3.2 percent in FY 2018, 3.0 percent in FY 2019 and 2.8 percent in FY 2020.¹⁴ The FY 2017 Medicaid budget also includes additional funding to cover increased costs associated with the phased-in increases to the hourly minimum wage rate, which is expected to increase annual Medicaid spending, above previously forecasted Global Cap limits.¹⁵

The FY 2017 budget also authorizes new middle class tax cuts that take effect in FY 2018, including a reduction in the marginal tax rates on middle incomes from 5.9 percent and 6.65 percent to 5.5 percent and 6 percent. These cuts are expected to reduce tax collections by $236 million in FY 2018, growing to $1.5 billion in FY 2020, on a cash basis. When fully effective in CY 2025, the tax reduction is estimated to reach $4.2 billion on a liability basis.¹⁶

ACA Implementation

New York is one of 31 states and the District of Columbia that have implemented the ACA Medicaid expansion and is one of 13 states that operate a state-based Marketplace.¹⁷ In FY 2015, New York also implemented a new program under an ACA coverage option called the “Basic Health Plan” (BHP). Under this ACA option, states may offer health coverage to individuals with family incomes between 133 and 200 percent of the federal poverty level (FPL) and for individuals from 0-200 percent FPL who are lawfully present in the United States but do not qualify for Medicaid due to their immigration status. This coverage takes the place of subsidized coverage in the Marketplace. States electing this option receive federal funding equal to 95 percent of the premium tax credit and the cost-sharing reductions that would have been provided for Marketplace coverage.¹⁸ New York is using the BHP authority and federal funding to offer the “Essential Plan” which has allowed the state to realize savings by transitioning certain Medicaid waiver populations and certain immigrants (previously covered with state-only dollars) to BHP coverage.¹⁹

Medicaid Redesign Team

After years of rapid growth, New York’s Medicaid program had per enrollee costs in FY 2011 that were far in excess of those in other states, but these higher expenditures had not produced correspondingly high quality results or rankings.²⁰ To address these concerns, Governor Cuomo appointed the Medicaid Redesign Team (MRT) to design strategies to lower Medicaid expenditure growth and improve quality in the program. The 27 member MRT is led by the Medicaid Director and includes representatives from various health care providers and stakeholders.²¹ Since its inception, more than 200 initiatives have been created as a result of the MRT addressing programmatic changes in the way health care is provided, reimbursed and managed to ensure that quality care is provided in the most efficient manner.²² During that time, Medicaid spending growth has not exceeded the Medicaid Global Cap (described above).

In 2012, the MRT issued a multi-year action plan that incorporated three broad Medicaid redesign strategies: increased reliance on managed care, development of new service delivery mechanisms and use of value-based payments.²³

Medicaid Managed Care

New York began contracting with capitated managed care organizations (MCOs) in the late 1980’s, and by 2010, approximately two-thirds of all Medicaid enrollees were enrolled in “mainstream” MCOs offering acute care services but excluding coverage for most long term services and supports (LTSS), prescription drugs, some dental care and behavioral health services. There were also several MCOs at that time specializing in LTSS (some offering both acute care and LTSS) serving about 40,000 Medicaid enrollees who voluntarily enrolled. ²⁴ In 2011, the MRT added prescription drugs, personal care, and some home health care to the mainstream MCO benefit package. Dental services (2012), hospice care (2013) and nursing home care (2015) were added later. Beginning in 2015, coverage of certain mental health services, including substance abuse treatment, began to be phased-in (through 2017). ²⁵

Since 2011, managed care enrollment has also become mandatory for a number of previously exempt groups including HIV positive individuals (2011), homeless individuals, low birth-weight infants, persons with end-stage renal disease (2012), and some foster care children (2013). Mandatory enrollment for adults receiving home and community-based services (HCBS) for an extended period of time was phased-in during 2012 and 2013, was applied to adults entering a nursing home in 2015, and will be applied to children entering a nursing home in 2017. ²⁶ Also, in 2015, the state implemented a voluntary Financial Alignment Demonstration with the Centers for Medicare and Medicaid Services (CMS) for persons dually eligible for Medicare and Medicaid that provides a comprehensive benefit including Medicare and Medicaid acute care and LTSS on a capitated basis by Fully Integrated Duals Advantage (FIDA) plans.

More recently, the state has begun to phase-in mandatory managed care for persons with severe mental illness (in FY 2016 and FY 2017) by contracting with specialized MCOs called “Health and Recovery Plans” (HARPs). An estimated 140,000 persons will be served in these plans.²⁷ Also, as part of the Financial Alignment Demonstration referred to above, the state currently contracts with one “FIDA-IDD” plan to provide coordinated care, on a voluntary basis, for people with intellectual and developmental disabilities who are eligible for both Medicare and Medicaid services. The FIDA-IDD plan provides Medicare and Medicaid benefits through an integrated benefit design that includes a dedicated interdisciplinary team to address each individual´s medical, behavioral, long-term supports and services, and social needs.²⁸

Delivery System Reform Incentive Payment Program (DSRIP)

In April 2014, CMS approved an amendment to New York’s existing Section 1115 waiver allowing the state to reinvest over a five-year period (2015-2019) $8 billion of the $17.1 billion in federal savings generated by MRT reforms.²⁹ From this total, $6.42 billion is to be used to implement delivery system reform incentive payment projects (the “DSRIP program”), $1.08 billion is for Health Home development and investments in long term care, workforce and enhanced behavioral health services, and $500 million in one-time funding will be used to assist safety net providers.^{30 31} New York’s DSRIP program is designed around 25 “Performing Provider Systems” (PPSs) – newly created provider partnerships who have agreed to cooperate and coordinate services for the Medicaid population in the counties they serve. The PPSs can receive DSRIP payments for implementing at least five reform projects from a list of 44 and meeting performance metrics.³² PPSs are coalitions of providers with a lead organization that is often a major medical center. Among the most frequently selected projects are primary care/behavioral health integration, integrated delivery systems, chronic disease transitions, and adult cardiovascular high risk management.³³ As of October 2016, the PPSs have received 99.4% of all available funds to date.

Value Based Payments

As a condition for approval of the DSRIP Section 1115 waiver amendment described above, and to ensure the long-term sustainability of the improvements made possible by the DSRIP investments, CMS required the State of New York to submit a multiyear Roadmap for comprehensive Medicaid payment reform including how the state would amend its MCO contracts. In June 2015, the New York State Department of Health released “A Path Toward Value Based Payment: New York State Roadmap for Medicaid Payment Reform,” (the “VBP Roadmap”).³⁴ The VBP Roadmap outlines the state’s strategy for assuring that 80-90 percent of MCO payments are shifted from fee-for-service (FFS) to VBP by 2020 and describes the new payment approaches and the types of provider organizations that will be involved.³⁵ In June 2016, the state released the results of MCO survey designed to get a baseline for measuring statewide progress toward the overall 80-90 percent VBP goal and towards a second goal that at least 35 percent of MCO payments to providers be risk-based VBP arrangements (at “Level 2 or 3” as defined in the VBP Roadmap).³⁶ Overall, the survey results indicated that 63.2 percent of MCO payments were FFS while 25.5 percent reflected VBP Levels 1-3. The remaining 11.3 percent reflected VBP “Level 0” (FFS payments with bonus and/or withhold based on quality scores)

Additional Medicaid policy actions taken in FY 2016 or planned for FY 2017 are described below.

Oklahoma

Economic and Budget Outlook

Economy and State Revenues

In recent years, Oklahoma has typically accounted for more than 3 percent of total U.S. oil production and almost one-tenth of the nation’s natural gas production.¹ It is one of seven states, along with Alaska, Louisiana, New Mexico, North Dakota, Texas and Wyoming, in which the oil and gas sector’s share of the state’s Gross Domestic Product (GDP), personal income and payroll employment is more than 3.5 times larger than in the nation as a whole.² Because of their heavy reliance on the oil and gas sectors, the economies of these states have been adversely affected to varying degrees by the price of oil which began falling in mid-2014.³ By December 2015, Oklahoma had lost 11,600 energy jobs and 59 percent of the state’s active oil and gas rigs.⁴ While crude oil prices had partially rebounded by the end of August 2016, they remained below the price in effect a year earlier and less than half of the July 2014 price. ^{5 6} Oklahoma’s unemployment rate rose for the sixth consecutive month in July 2016 to 5.0 percent (compared to 4.3 percent in July 2015), exceeding the national rate (4.9 percent) for the first time in 26 years.⁷

⁸Falling oil prices have also negatively impacted state General Revenue Fund (GRF) collections. At the end of FY 2016, state GRF collections were $541.3 million (9.4%) below official estimates and $521.9 million (9.1%) below prior year collections.⁹ Oklahoma’s constitution prohibits revenue increases without approval of three quarters of both the House and Senate or a vote of the people, limiting the state’s ability to raise taxes in response to budget issues.¹⁰

State Budget

On June 1, 2015, Governor Mary Fallin signed into law the FY 2016 budget, praising legislators for closing a $611 million shortfall without cutting funding for K-12 education. The FY 2016 budget was 1.03 percent less than the FY 2015 appropriated budget.¹¹ By December 2015, low GRF collections, triggered a “revenue failure” declaration which forced across the board spending cuts as well as a one-time appropriation of $500 million from the Day Fund and from other cash reserves to balance the budget.¹²

As lawmakers worked to balance the FY 2016 budget, they were also faced with a $1.3 billion shortfall for the FY 2017 budget, the largest in the state’s history.¹³ Public schools feared aid reductions of up to 20 percent while the Oklahoma Health Care Authority (OHCA), which administers the state’s Medicaid program, prepared to implement provider rate cuts of up to 25 percent that would have jeopardized the ability of some hospitals and nursing homes to remain open.¹⁴ The final FY 2017 budget, signed into law by Governor Fallin on June 10, 2016, averted these outcomes maintaining current funding levels for the State Department of Education and adding $83.8 million in appropriations for the OHCA (one of four agencies to receive an increase), while also keeping the state’s eight-year transportation infrastructure plan intact.^{15 16} The FY 2017 budget also eliminated or reduced various tax breaks, relies on a number of dedicated fund transfers including $66 million from the Rainy Day Fund, and $200 million in transportation bonds.¹⁷  Overall, the FY 2017 budget of $6.8 billion is $360.7 million (5%) less than the FY 2016 budget prior to the mid-year revenue failure and $67.8 million (1%) less than the FY 2016 appropriations as adjusted by the mid-year revenue failure.¹⁸

When the state completed its final reconciliation of FY 2016 state revenues in July 2016, it determined that the mid-year reductions imposed in December 2015 and February 2016 were deeper than necessary and funds were returned to state agencies instead.¹⁹

ACA Medicaid Expansion

As a result of the 2012 Supreme Court decision, Oklahoma has not adopted the ACA Medicaid expansion. In April 2016, faced with dwindling reserves, enrollment growth, and budget deficits, Governor Fallin and the CEO of OHCA, Nico Gomez, proposed the Medicaid Rebalancing Act of 2020 legislation, an alternative Medicaid expansion proposal.  The plan would have provided coverage through a Private Option for Oklahomans age 19 to 64 with incomes at or below 138 percent of the federal poverty level (FPL) (similar to Arkansas using Medicaid funds to purchase coverage for enrollees from the Marketplace).  In addition, the plan called for 175,000 pregnant women and children with Medicaid coverage to transition to coverage in the Marketplaces. The proposed plan also called for creating member health savings accounts, called “HealthStead accounts,” that would help pay for medical expenses with financial incentives for healthy lifestyle choices, and partially finance it with an increase in the cigarette tax of $1.50 per pack.²⁰ The plan was expected to reduce the number of uninsured by 30 percent, stimulate the economy and generate state savings of $55 million.²¹ The Plan failed to receive legislative approval, after some lawmakers labeled it a Medicaid expansion under the ACA. Legislators also could not agree on revenue enhancing measures such as a cigarette tax to help fund the proposal.²²

Medicaid Managed Care and Other Payment and Delivery System Reforms

In 1996, Oklahoma implemented managed care, branded as SoonerCare, which initially consisted of two programs: (1) SoonerCare Plus, which contracted with health plans in urban areas of the state using a fully capitated delivery system and (2) SoonerCare Choice – a primary care case management (PCCM) program – which provided services in rural areas of the state. In 2004, SoonerCare Choice expanded statewide and became the sole model of care in the state, supplanting the fully capitated risk based managed care system. This program provided most Medicaid beneficiaries with acute, primary, specialty, and behavioral health services on a fee-for-service (FFS) basis; care coordination services and limited primary care services were covered through a fixed per member per month fee paid to contracted primary care providers.

Since 2004, Oklahoma has implemented other initiatives to promote cost-effective care and improved health outcomes. In 2006, the state began the Health Management Program (HMP) to conduct intensive nurse case management with the highest need patients and facilitate practice transformation. Under the HMP, Oklahoma contracts directly with primary care physicians to provide primary care and care coordination services, and pays them a monthly case management fee that is risk-adjusted to reflect variations in the expected service intensity for patients served in each medical home. Three local non-profit organizations serve as Health Access Networks, which receive a nominal per member per month payment to provide care management to persons with complex needs, in addition to the monthly case management fee paid to individual primary care providers. In 2009, Oklahoma also adopted a patient-centered medical home model for SoonerCare Choice in which primary care providers are paid a bundled care coordination payment and are eligible for additional performance payments; all medical services continue to be paid on a FFS basis. Children and families, pregnant women, children and adults with disabilities, and older adults are mandatorily enrolled in the program; American Indians/Alaska Natives have the choice of selecting either an Indian Health Service (IHS) or non-IHS provider to under SoonerCare.

As of July 2016, 74.8 percent of total SoonerCare enrollees were enrolled in the state’s PCCM program. The state also operates Insure Oklahoma, an Employer-Sponsored Insurance (ESI) program where premium costs are shared by the state (60 percent), the employer (25 percent) and the employee (15 percent).²³

Recent Delivery System Reform Initiatives and Quality Improvements

Despite ongoing budget challenges, the OHCA continues to move forward with the delivery system reform and quality improvement initiatives described below.

SoonerHealth+: Care Coordination for the ABD Population

In 2015, the United Health Foundation’s Senior Health Rankings ranked Oklahoma 46th in the nation.²⁴ Several factors considered in this ranking include nursing home quality, hospital readmission rates, chronic health conditions, and community involvement. According to the report, there is a high prevalence of physical inactivity among Oklahoma’s senior population, and a low percentage of seniors in the state receive health screenings and recommended hospital care. This low health ranking suggests that Oklahoma will face additional challenges caring for the baby boomer generation in the years to come.

With the intent of providing better access to care, improving quality and health outcomes, and controlling costs for the Medicaid aged, blind, and disabled (ABD) populations, the state legislature passed legislation in 2015 requiring the OHCA to create an ABD care coordination program. The “SoonerHealth+” program will be a fully capitated program implemented statewide with services beginning in April 2018.²⁵ According to the 2015 legislation, members receiving institutional care will be phased-in two years after the initial program enrollment period. The state expects to release a Request for Proposals (RFP) that includes model contract standards for managed care organizations (MCOs) in November 2016. OHCA plans to use a third party options counselor to assist members with plan choice. PACE will continue to be an option for eligibles in lieu of an MCO. Behavioral Health Homes will also continue to serve qualified members in lieu of MCO enrollment, and MCOs will be required to have Patient Centered Medical Homes for their Medicaid members.²⁶

CMMI CPC and CPC+

Oklahoma is one of 14 states and regions recently awarded a Center for Medicare and Medicaid Innovation (CMMI) grant for the Comprehensive Primary Care Plus program (CPC+) program. The five-year multi-payer advanced primary care medical home model grant begins in January 2017 and builds on the earlier Comprehensive Primary Care (CPC) initiative that began in October 2012 and runs through December 31, 2016. The greater Tulsa region is one of seven markets participating in the CPC initiative.²⁷ The CPC+ program will include advances in payment to support primary care practices to provide more comprehensive care that meets the needs of all of their patients, particularly those with complex needs.²⁸

CPC+ has two tracks for physician practices. Track 1 features a relatively simple financial model and less ambitious clinical goals than Track 2. Practices in both tracks are expected to make changes to address key CPC functions: (1) access and continuity; (2) care management; (3) comprehensiveness and coordination; (4) patient and caregiver engagement, and (5) planned care and population health. Highlights of the Track 1 model include physician practices receiving a per beneficiary per month (PBPM) care management fee ranging from $6 to $30. In addition, a performance-based payment incentive as high as $2.50 PBPM will be paid to primary care practices at the beginning of a CPC+ performance year. The Track 2 model includes a PBPM care management fee based on a five-tier risk-stratification scale. The lowest four tiers mirror the risk-stratification scale for Track 1, with fees ranging from $9 to $33. In the fifth tier, physician practices can earn a $100 PBPM fee for treating high-risk patients. In addition, a performance-based payment incentive as high as $4 PBPM will be paid to primary care practices at the beginning of a CPC+ performance year.²⁹

Supportive Housing

Recognizing that stable housing is a critical element of healthy living, OHCA staff assist SoonerCare members with affordable housing support services.  In 2016-2017, OHCA will target persons with physical disabilities and persons with intellectual and developmental disabilities for this support, and has created a Social Supports and Outreach unit dedicated to assisting members with housing or other community supports.³⁰

Additional Medicaid policy actions taken in FY 2016 or planned for FY 2017 are described below.

Endnotes

Introduction

1. Centers for Medicare and Medicaid Services. National Health Expenditures (Washington, DC: Centers for Medicare and Medicaid Services, December 2015). http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/NationalHealthExpendData/NationalHealthAccountsHistorical.html.

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Issue Brief

Maryland

1. U.S. Department of Commerce, Bureau of Economic Analysis. GDP for Maryland (Washington, DC: U.S. Department of Commerce, accessed September 27, 2016). http://www.bea.gov/regional/bearfacts/action.cfm?geoType=3&fips=24000&areatype=24000.

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2. U.S. Department of Labor, Bureau of Labor Statistics. Databases, Tables & Calculators by Subject (Washington, DC: U.S. Department of Labor, accessed September 27, 2016). http://data.bls.gov/timeseries/LASST240000000000003?data_tool=XGtable.

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3. State of Maryland Board of Revenue Estimates. Maryland General Fund Revenues September 2016 Update (Annapolis, MD: State of Maryland Board of Revenue Estimates, September 21, 2016).  http://finances.marylandtaxes.com/static_files/revenue/BRE_reports/FYI_2017/2016_BRE_September_Revision.pdf.

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4. The Office of Governor Larry Hogan. Governor Larry Hogan Announces Fiscal Year 2017 Budget (Annapolis, MD: The Office of Governor Larry Hogan, January 20, 2016). http://governor.maryland.gov/2016/01/20/governor-larry-hogan-announces-fiscal-year-2017-budget/

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5. Maryland Department of Budget and Management. FY2017 Fiscal Digest (Annapolis, MD: Maryland Department of Budget and Management, accessed September 27, 2016). http://www.dbm.maryland.gov/budget/Pages/operbudget/2017-FiscalDigest.aspx.

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6. Maryland Department of Health and Mental Hygiene. Maryland Chronic Health Homes (Baltimore, MD: Department of Health and Mental Hygiene, accessed September 27, 2016) https://mmcp.dhmh.maryland.gov/pages/health-homes.aspx.

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7. The RTCW had been offered under a Congressionally authorized, but time-limited, 1915(c) waiver pilot to provide HCBS for children who would otherwise be served in an inpatient Psychiatric Residential Treatment Facility.

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8. Maryland Department of Health and Mental Hygiene. 1915(i) Intensive Behavioral Health Services for Children, Youth and Families (Baltimore, MD: Department of Health and Mental Hygiene, accessed September 27, 2016) https://mmcp.dhmh.maryland.gov/pages/1915(i)-Intensive-Behavioral-Health-Services-for-Children,-Youth-and-Families.aspx.

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9. Centers for Medicare and Medicaid Services. Balancing Incentive Program (Baltimore, MD: Centers for Medicare and Medicaid Services, accessed September 27, 2016) https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/balancing/balancing-incentive-program.html.

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10. Maryland Department of Health and Mental Hygiene. 1115 HealthChoice Waiver Renwal (Baltimore, MD: Department of Health and Mental Hygiene, accessed September 27, 2016) https://mmcp.dhmh.maryland.gov/Pages/1115-HealthChoice-Waiver-Renewal.aspx.

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11. Links to the Maryland HealthChoice Waiver Renewal summary and full application can be found at: https://mmcp.dhmh.maryland.gov/Pages/1115-HealthChoice-Waiver-Renewal.aspx.

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12. On July 27, 2015, CMS issued a State Health Officials letter (SHO) that outlined an opportunity for such waiver coverage for states seeking to demonstrate the effectiveness of a comprehensive, evidence-based approach to substance use disorder treatment. The SHO can be found at: https://www.medicaid.gov/federal-policy-guidance/downloads/SMD15003.pdf.

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13. Centers for Medicare and Medicaid Services. Maryland All-Payer Model (Baltimore, MD: Centers for Medicare and Medicaid Services, accessed September 27, 2016) https://innovation.cms.gov/initiatives/Maryland-All-Payer-Model/.

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14. Health Services Cost Review Commission. Maryland All-Payer Model Agreement (Baltimore, MD: Health Services Cost Review Commission, February 11, 2014). http://www.hscrc.state.md.us/documents/md-maphs/stkh/MD-All-Payer-Model-Agreement-(executed).pdf.

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15. Centers for Medicare and Medicaid Services. Maryland All-Payer Model (Baltimore, MD: Centers for Medicare and Medicaid Services, accessed September 27, 2016) https://innovation.cms.gov/initiatives/Maryland-All-Payer-Model/.

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16. Maryland Health Care Commission. Maryland Medical Care Data Base (MCDB) (Baltimore, MD: Department of Health and Mental Hygiene, accessed September 27, 2016).  http://mhcc.maryland.gov/mhcc/pages/apcd/apcd_mcdb/apcd_mcdb.aspx.

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17. Maryland Department of Health and Mental Hygiene. Medicaid and Medicare Dual Eligibles Care Delivery Strategy (Baltimore, MD: Department of Health and Mental Hygiene, accessed September 27, 2016) https://mmcp.dhmh.maryland.gov/sim/Pages/Home.aspx.

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18. Maryland Department of Health and Mental Hygiene. Overdose Prevention in Maryland (Baltimore, MD: Department of Health and Mental Hygiene, accessed September 27, 2016)  http://bha.dhmh.maryland.gov/OVERDOSE_PREVENTION/Pages/Index.aspx.

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19. Meredith Cohn. Overdose Deaths in Maryland Continued Grim Spike Last Year (Baltimore, MD: The Baltimore Sun, June 9, 2016) http://www.baltimoresun.com/health/bs-hs-heroin-overdoses-20160609-story.html. Heroin-related fatal overdoses role 29 percent; deaths from Fentanyl rose 83 percent.

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Montana

1. University of Montana Bureau of Business and Economic Research. The State and National Economic Outlook: Back to Full Employment (Missoula, MT: Bureau of Business and Economic Research, 2016) http://www.bber.umt.edu/pubs/econ/CountyOutlooks/16MT.pdf;

   University of Montana Bureau of Business and Economic Research. Montana Economic Report (Missoula, MT: Bureau of Business and Economic Research, 2016) http://www.bber.umt.edu/pubs/Seminars/2016/EconRpt2016.pdf.

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2. Census & Economic Information Center. CEIC Industry Dashboard (Helena, MT: Department of Commerce, accessed September 27, 2016) http://ceic.mt.gov/Economics/IndustryDashboard.aspx.

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3. U.S. Bureau of Labor Statistics. Regional and State Employment and Unemployment Summary (Washington, DC: U.S. Department of Labor, August 19, 2016) http://www.bls.gov/news.release/laus.nr0.htm.

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4. Matt Volz. Montana’s Economic Health Emerges as Election Factor (Kalispell, MT: Flathead Beacon, September 7, 2016) http://flatheadbeacon.com/2016/09/07/montanas-economic-health-emerges-election-factor/.

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5. Governor’s Office of Budget and Program Planning. Governor’s Budget Fiscal years 2016 – 2017: Economic Overview (Helena, MT: Governor’s Office of Budget and Program Planning, June 2014) https://budget.mt.gov/Portals/29/execbudgets/2017_Budget/Volume_2.pdf

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6. Montana Legislative Fiscal Division. General Fund Updated Revenue Trends (Helena, MT: Legislative Fiscal Division, September 7, 2016) http://leg.mt.gov/content/Committees/Interim/2015-2016/Revenue-and-Transportation/Meetings/Sept-2016/lfd-revenue-trends-2016.pdf.

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7. Ibid.

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8. Montana Legislative Fiscal Division. FY 2015 FYE Report (Helena, MT: Legislative Fiscal Division, September 24, 2015) http://leg.mt.gov/content/Committees/Interim/2015-2016/Revenue-and-Transportation/Meetings/Sept-2015/FYE2015-Report.pdf.

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9. Governor’s Office of Budget and Program Planning. Governor’s Budget Highlights Fiscal Years 2016 -2017 (Helena, MT: Governor’s Office of Budget and Program Planning, November 2014) https://budget.mt.gov/Portals/29/execbudgets/2017_Budget/Orange%20Book.pdf.

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10. Jackie Yamanaka. Medicaid Expansion Passes House In Saturday Vote, Now Back To Senate (Missoula, MT: Montana Public Radio, April 12, 2015)  http://mtpr.org/post/medicaid-expansion-passes-house-saturday-vote-now-back-senate.

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11. Montana State 64^th Legislature. An Act Appropriating Money to Various State Agencies for the Bienniums Ending June 30, 2015, and Ending June 30, 2017; And Providing Effective Dates (HB0002) (Missoula, MT: Montana State Legislature, 2015) http://leg.mt.gov/bills/2015/billpdf/HB0002.pdf.

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12. Lisa Baumann Gov. Introduces Proposal for Medicaid Expansion (Great Falls, MT: Great Falls Tribune, January 19, 2015) http://www.greatfallstribune.com/story/news/local/2015/01/19/gov-introduces-proposal-medicaid-expansion/22009775/.

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13. Eric Whitney. Why Montana Hospitals Back Bullocks Medicaid Expansion Plan (Missoula, MT: Montana Public Radio, March 3, 2015) http://mtpr.org/post/why-montana-hospitals-back-bullocks-medicaid-expansion-plan.

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14. Jackie Yamanaka. Montana Republicans Unveil Healthcare Plan, Minus Medicaid Expansion (Missoula, MT: Montana Public Radio, February 10, 2015)  http://mtpr.org/post/montana-republicans-unveil-healthcare-plan-minus-medicaid-expansion.

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15. Eric Whitney. Montana Senate Republicans Release Health Plan (Missoula, MT: Montana Public Radio, December 31, 2014) http://mtpr.org/post/montana-senate-republicans-release-health-plan.

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16. Josh Burnham. Governor's Medicaid Expansion Bill Killed On Party Line Vote (Missoula, MT: Montana Public Radio, March 6, 2015) http://mtpr.org/post/governors-medicaid-expansion-bill-killed-party-line-vote.

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17. Steve Jess. Democrats Cry Foul Over Medicaid Expansion Vote (Missoula, MT: Montana Public Radio, March 9, 2015) http://mtpr.org/post/democrats-cry-foul-over-medicaid-expansion-vote.

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18. Steve Jess. Sen. Buttrey Seeks Compromise With His Health Care Plan (Missoula, MT: Montana Public Radio, March 20, 2015) http://mtpr.org/post/sen-buttrey-seeks-compromise-his-health-care-plan.

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19. Jackie Yamanaka. Medicaid Expansion Passes House In Saturday Vote, Now Back To Senate (Missoula, MT: Montana Public Radio, April 12, 2015) http://mtpr.org/post/medicaid-expansion-passes-house-saturday-vote-now-back-senate.

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20. Centers for Medicare and Medicaid Services. Montana Health and Economic Livelihood Partnership (HELP) Program Approved 1115 Waiver (Baltimore, MD: Centers for Medicare and Medicaid Services, December 30, 2015) https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mt/mt-HELP-program-ca.pdf.

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21. Exempt groups include those with incomes at or below 50 percent FPL, American Indian/Alaskan Natives, individuals who are medically frail, those with exceptional health care needs as determined by the state, people who live in regions where there are insufficient number of providers contracted with the TPA, and people who require continuity of coverage not available or effectively delivery through the TAP.

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22. HELP Act Oversight Committee. Report to the Governor and Legislative Finance Committee (Helena, MT: Department of Public Health and Human Services, July 15, 2016,) http://dphhs.mt.gov/Portals/85/Documents/MedicaidExpansion/HELP%20Act%20Oversight%20Committee%20Report%20FINAL7_15_2016.pdf.

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23. Ibid.

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24. Ibid.

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25. Ibid.

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26. The Kaiser Commission on Medicaid and the Uninsured. Medicaid Expansion in Montana (Washington, DC: The Kaiser Family Foundation, November 20, 2015) https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-montana/.

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27. HELP Act Oversight Committee. Report to the Governor and Legislative Finance Committee (Helena, MT: Department of Public Health and Human Services, July 15, 2016,) http://dphhs.mt.gov/Portals/85/Documents/MedicaidExpansion/HELP%20Act%20Oversight%20Committee%20Report%20FINAL7_15_2016.pdf.

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New York

1. Alex Gray. Which American state has a bigger economy than India (Geneva, Switzerland: World Economic Forum, July 8, 2016)  https://www.weforum.org/agenda/2016/07/american-state-bigger-economy-than-india/.

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2. New York State Assembly Ways and Means Committee. Economic and Revenue Report, Fiscal Years 2015-16 and 2016-17 (Albany, NY: New York State Assembly Ways and Means Committee, February 2016) http://assembly.state.ny.us/Reports/WAM/2016economic_revenue/2016ecrev.pdf.

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3. Bureau of Economic Analysis. New York (Washington, DC: U.S. Department of Commerce, accessed September 27, 2016) http://www.bea.gov/regional/bearfacts/pdf.cfm?fips=36000&areatype=STATE&geotype=3.

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4. Bureau of Economic Analysis. Gross Domestic Product by State: First Quarter 2016 (Washington, DC: U.S. Department of Commerce, accessed July 27, 2016) http://www.bea.gov/newsreleases/regional/gdp_state/2016/pdf/qgsp0716.pdf.

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5. New York State Department of Labor. Unemployment Rate Drops to 4.7% in May Lowest Level Since August 2007 (Albany, NY: Department of Labor, June 16, 2016) http://www.labor.ny.gov/pressreleases/2016/june-16-2016.shtm.

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6. HMA calculations based on fiscal year end results published by the New York State Division of the Budget in the Enacted Budget Financial Plan for FYs 2015, 2016 and 2017, Census table 3 (Albany, NY: Division of the Budget, accessed September 27, 2016) http://openbudget.ny.gov/budgetArchives.html.

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7. New York State Division of the Budget. FY 2017 Financial Plan First Quarterly Update (Albany, NY: Division of the Budget, August 2016) https://www.budget.ny.gov/budgetFP/FY2017FPQ1.pdf.

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8. New York State Division of the Budget. FY 2017 Enacted Budget Financial Plan (Albany, NY: Division of the Budget, May 2016) https://www.budget.ny.gov/budgetFP/FY2017FP.pdf.

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9. Office of Governor Cuomo. Governor Cuomo and Legislative Leaders Announce Agreement on 2016-17 State Budget (Albany, NY: Division of the Budget, March 31, 2016) https://www.budget.ny.gov/pubs/press/2016/pressRelease16_enacted.html.

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10. New York State Division of the Budget. FY 2017 Enacted Budget Financial Plan (Albany, NY: Division of the Budget, May 2016) https://www.budget.ny.gov/budgetFP/FY2017FP.pdf.

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11. Office of Governor Cuomo. Governor Cuomo and Legislative Leaders Announce Agreement on 2016-17 State Budget (Albany, NY: Division of the Budget, March 31, 2016) https://www.budget.ny.gov/pubs/press/2016/pressRelease16_enacted.html.

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12. Ibid.

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13. Ibid.

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14. New York State Division of the Budget. FY 2017 Financial Plan First Quarterly Update (Albany, NY: Division of the Budget, August 2016) https://www.budget.ny.gov/budgetFP/FY2017FPQ1.pdf.

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15. Ibid.

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16. Ibid.

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17. Kaiser Family Foundation State Health Facts. “State Health Insurance Marketplace Types.” Data Source: Data compiled through review of state legislation and other Marketplace documents by the Kaiser Family Foundation, 2016. Accessed September 27, 2017. https://www.kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/.

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18. Centers for Medicare and Medicaid Services. New York Basic Health Program Blueprint (Baltimore, MD: Centers for Medicare and Medicaid Services, September 2015) https://www.medicaid.gov/basic-health-program/downloads/ny-blueprint.pdf.

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19. V. Smith, K. Gifford, E. Ellis, R. Rudowitz, L. Snyder and E. Hinton. Medicaid Reforms to Expand Coverage, Control Costs and Improve Care: Results form a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016. (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, October 2015) http://files.kff.org/attachment/report-medicaid-reforms-to-expand-coverage-control-costs-and-improve-care-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2015-and-2016.

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20. Citizens Budget Commission. What Ails Medicaid in New York, And Does the Medicaid Redesign Team Have a Cure? (New York, NY: Citizens Budget Commission, May 20, 2016) http://www.cbcny.org/content/what-ails-medicaid-new-york-and-does-medicaid-redesign-team-have-cure.

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21. Ibid.

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22. New York State Department of Health. Redesigning New York’s Medicaid Program (Albany, NY: Department of Health, accessed September 27, 2016) https://www.health.ny.gov/health_care/medicaid/redesign/.

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23. Citizens Budget Commission. What Ails Medicaid in New York, And Does the Medicaid Redesign Team Have a Cure? (New York, NY: Citizens Budget Commission, May 20, 2016) http://www.cbcny.org/content/what-ails-medicaid-new-york-and-does-medicaid-redesign-team-have-cure.

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24. Ibid.

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25. Ibid.

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26. Ibid.

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27. Ibid.

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28. New York State Office for People with Developmental Disabilities. Fully Integrated Duals Advantage (Albany, NY: Office for People with Developmental Disabilities, accessed September 27, 2016) https://www.opwdd.ny.gov/opwdd_services_supports/people_first_waiver/care_management/FIDA_IDD.

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29. Citizens Budget Commission. What Ails Medicaid in New York, And Does the Medicaid Redesign Team Have a Cure? (New York, NY: Citizens Budget Commission, May 20, 2016) http://www.cbcny.org/content/what-ails-medicaid-new-york-and-does-medicaid-redesign-team-have-cure.

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30. New York State Department of Health. DSRIP Overview (Albany, NY: Department of Health, accessed September 27, 2016) http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/overview.htm.

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31. Jocelyn Guyer, Naomi Shine, Robin Rudowitz, and Alexandra Gates. Key Themes from Delivery System Reform Incentive Payment (DSRIP) Waivers in 4 States. (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, April 2015) http://files.kff.org/attachment/issue-brief-key-themes-from-delivery-system-reform-incentive-payment-dsrip-waivers-in-4-states.

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32. Ibid.

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33. Citizens Budget Commission. What Ails Medicaid in New York, And Does the Medicaid Redesign Team Have a Cure? (New York, NY: Citizens Budget Commission, May 20, 2016) http://www.cbcny.org/content/what-ails-medicaid-new-york-and-does-medicaid-redesign-team-have-cure.

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34. New York State Department of Health. A Path Toward Value Based Payment (Albany, NY: Department of Health, June 2015) https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/vbp_roadmap_final.pdf.

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35. Rob Houston, Katherine Heflin and Tricia McGinnis, Navigating the New York State Value-Based Payment Roadmap (New York, NY: Medicaid Institute at the United Hospital Fund, November 2015) https://www.uhfnyc.org/assets/1439.

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36. New York State Department of Health. Managed Care Organization (MCO) Baseline Survey – Results (Albany, NY: Department of Health, June 28, 2016) https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_library/docs/2016-07-25_mco_survey_results.pdf.

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Oklahoma

1. Oklahoma Employment Security Commission. Oklahoma Economic Indicators (Oklahoma City, OK: Oklahoma Employment Security Commission, August 2016) https://www.ok.gov/oesc_web/documents/lmiEconIndPub.pdf.

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2. Chad Wilkerson. How is Oklahoma’s economy performing relative to other oil and gas states (Oklahoma City, OK: Federal Reserve Bank of Kansas City, June 9, 2016) https://www.kansascityfed.org/publications/research/oke/articles/2016/comparing-oklahomas-economy.

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3. Ibid.

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4. Office of Management & Enterprise Services. Weak GRF receipts to cause revenue failure this fiscal year (Oklahoma City, OK: Office of Management and Enterprise Services, December 15, 2015) https://content.govdelivery.com/accounts/OKOMES/bulletins/12b1e2f.

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5. Oklahoma Employment Security Commission. Oklahoma Economic Indicators (Oklahoma City, OK: Oklahoma Employment Security Commission, August 2016) https://www.ok.gov/oesc_web/documents/lmiEconIndPub.pdf.

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6. U.S. Energy Information Administration. Petroleum & Other Liquids (Washington, DC: U.S. Department of Energy, accessed September 27, 2016) https://www.eia.gov/dnav/pet/hist/LeafHandler.ashx?n=PET&s=RWTC&f=D.

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7. Oklahoma Employment Security Commission. Oklahoma Economic Indicators (Oklahoma City, OK: Oklahoma Employment Security Commission, August 2016) https://www.ok.gov/oesc_web/documents/lmiEconIndPub.pdf.

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8. NewsChannel4. Oklahoma unemployment rate tops national average for first time in 26 years (Oklahoma City, OK: NewsChannel4, September 6, 2016) http://kfor.com/2016/09/06/oklahoma-unemployment-rate-tops-national-average-for-first-time-in-13-years/.

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9. Office of Management & Enterprise Services. Final FY 2016 revenues 9.4% below estimate (Oklahoma City, OK: Office of Management & Enterprise Services, July 27, 2016) https://content.govdelivery.com/accounts/OKOMES/bulletins/15930ad.

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10. Office of the State Treasurer. Oklahoma Economic Report (Oklahoma City: OK, Office of the State Treasurer, Volume 5 Issue 12, December 31, 2015) https://www.ok.gov/treasurer/documents/OER_12-31-15.pdf.

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11. Office of Governor Mary Fallin. Gov. Fallin Signs Budget Bill, Highlights Successes in 2015 Legislative Session (Oklahoma City, OK: Office of Governor Mary Fallin, June 1, 2015) https://www.ok.gov/triton/modules/newsroom/newsroom_article.php?id=223&article_id=15912.

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12. Oklahoma Policy Institute. Budget Trends and Outlook – March 2016 (Tulsa, OK: Oklahoma Policy Institute, March 4, 2016) http://okpolicy.org/budget-trends-and-outlook-march-2016/.

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13. Office of Governor Mary Fallin. Gov. Fallin Signs Budget Bill, Acts on Other Measures to Close out 2016 Legislative Session (Oklahoma City, OK: Office of Governor Mary Fallin, June 10, 2016)  https://www.ok.gov/triton/modules/newsroom/newsroom_article.php?id=223&article_id=22720.

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14. News9.com. Oklahoma Governor, Lawmaker Reach Budget Agreement (Oklahoma City, OK: News9.com, May 24, 2016) http://www.news9.com/story/32051727/oklahoma-lawmakers-reach-budget-agreement.

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15. Office of Governor Mary Fallin. Gov. Fallin Signs Budget Bill, Acts on Other Measures to Close out 2016 Legislative Session (Oklahoma City, OK: Office of Governor Mary Fallin, June 10, 2016)  https://www.ok.gov/triton/modules/newsroom/newsroom_article.php?id=223&article_id=22720.

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16. Ibid. (The Tax Commission, Elections Board and Legislative Services Bureau were the other agencies to receive an increase).

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17. Ibid.

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18. Ibid.

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19. Rick Green. Oklahoma governor decides against special session for teacher raises (Oklahoma City, OK: The Oklahoman, September 1, 2016) http://newsok.com/oklahoma-governor-decides-against-special-session-for-teacher-raises/article/5516389.

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20. Associated Press. Tobacco tax for Medicaid plan faces challenge in Oklahoma (Chicago, IL: Modern Healthcare, April 30, 2016) http://www.modernhealthcare.com/article/20160430/NEWS/304309937.

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21. Oklahoma Health Care Authority. Medicaid Rebalancing act of 2020 (Oklahoma City, OK: Oklahoma Health Care Authority, April 2016) https://www.okhca.org/about.aspx?id=18804.

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22. Rick Green. Oklahoma Health Care Authority official resigns, takes job with nursing home group (Oklahoma City, OK: The Oklahoman, August 31, 2016) http://newsok.com/article/5516184.

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23. Oklahoma Health Care Authority. Data and Reports - Insure Oklahoma Fast Facts (Oklahoma City, OK: Oklahoma Health Care Authority, August 2016) http://www.okhca.org/research.aspx?id=87&parts=7447.

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24. Oklahoma’s ranking dropped to 49^th in the most recent 2016 report. United Health Foundation. America’s Health Rankings Senior Report (Minnetonka, MN: United Health Foundation, 2016) http://assets.americashealthrankings.org/app/uploads/final-report-seniors-2016-edition-1.pdf.

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25. The Pacific Health Policy Group, “Presentation to the SoonerHealth+ Stakeholder Meeting,” July 26, 2016; accessed at http://okhca.org/about.aspx?id=17366.

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26. Oklahoma Health Care Authority. Health Care Model Advances (Oklahoma City, OK: Oklahoma Health Care Authority, August 31, 2016) http://okhca.org/about.aspx?id=17366.

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27. Centers for Medicare & Medicaid Services. Comprehensive Primary Care Plus (Baltimore, MD: Centers for Medicare & Medicaid Services, accessed September 27, 2016) https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus/.

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28. Centers for Medicare & Medicaid Services. Comprehensive Primary Care Plus (CPC+) Fact Sheet (Baltimore, MD: Centers for Medicare & Medicaid Services, April 11, 2016) https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-11.html.

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29. Ibid.

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30. V. Smith, K. Gifford, E. Ellis, R. Rudowitz, L. Snyder and E. Hinton. Medicaid Reforms to Expand Coverage, Control Costs and Improve Care: Results form a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016. (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, October 2015) http://files.kff.org/attachment/report-medicaid-reforms-to-expand-coverage-control-costs-and-improve-care-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2015-and-2016.

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