EAST

THE COUNCIL OF STATE GOVERNMENTS | AUGUST 2012

THE BOOK OF THE STATES 2012 Facts & Figures

NATIONAL ANALYSIS: STATES MEDICAID SPENDING GROWING
States face a huge decision before 2014. In its June 2012 decision on the Affordable Care Act, the U.S. Supreme Court placed in states hands the decision whether to expand eligibility for Medicaid to 133 percent of the federal poverty level. Currently, states provide Medicaid coverage to some adults with eligible children setting state eligibility at various percentages less than the federal poverty level. Non-disabled adults without children are not eligible for Medicaid, under current rules. If states decide to expand Medicaid to previously uncovered low-income individuals, the laws matching provisions provide 100 percent federal funding for the first three years. The federal funding gradually decreases through 2020, when the federal match reaches 90 percent. The 90 percent matching provision is more favorable to states than current Medicaid or Childrens Health Insurance Program, or CHIP, match rates. Data show that Medicaid expenditures have grown between 2007 and 2011. Medicaid expenditures by states, as a percentage of overall budget expenditures, also have grown during that time. Medicaids share of the state budget pie now exceeds that of primary and secondary education, the traditional number one budget priority for states.1 As state policymakers grapple with the decision regarding Medicaid eligibility expansion, they must consider whether increased Medicaid obligations will displace other budget priorities and whether states can sustain Medicaid budget growth, even with the favorable match rate for the expansion population. Growth in expenditures for Medicaid reflects increased enrollment driven by unemployment during and following the Great Recession. Like overall health care spending, the average annual increase in Medicaid spending has moderated in recent years and, in fact, the average annual growth in Medicaid spending lags behind the growth in all health care spending.2 The federal stimulus package provided an enhanced federal Medicaid matching rate to states between 2008 and 2011; that enhanced match rate relieved some of the burden on states to provide increased general funds to Medicaid. This obligation, however, came roaring back to states in July 2011 when the enhanced federal Medicaid matching rates were discontinued.3

MEDICAID EXPENDITURES AS PERCENT Growth in Medicaid Expenditures, OF TOTAL STATE fEXPENDITURES, 2007-2011 adjusted or ina8on, 2007-2011
45% 40% 35% 30% 25% 20% 15% 10% 5% 0%

Medicaid Expenditures Grew in the States from 2007 to 2011.

Na+onal Average

East Region Midwest Region South Region

West Region

West Region without California

Nationally, state Medicaid expenditures grew 20.4 percent between 2007 and 2011. Regionally, Medicaid expenditures grew twice as much in the Western states as the national average, with a 41.7 percent increase in the four-year period. The growth in the West region without California is 30 percent, still considerably higher than the national average. Medicaid spending increases in the Midwest and East were slightly less than the national average, at 17.4 and 16.5 percent respectively. The Southern states posted just an 8.4 percent expenditure increase over the four-year period.

State Medicaid Expenditures Grew as a Percent of Total State Expenditures.

According to National Association of State Budget Officers (NASBO) state expenditure data, the share of total state budgets spent on Medicaid has increased from an average of 20.9 percent in 2007 to 23.6 in 2011, a 2.7 percentage point increase. NASBO data also show that every region experienced growth in the proportion of state budget expenditures for Medicaid between 2007 and 2011.

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The West experienced the greatest growth, a 4.1 percentage point increase, while the South had the smallest growth at 0.5 percentage point. The percentage point increases in the East and Midwest were more similar to the national rate, at 2.1 for the East and 1.4 for the Midwest. In its "2010 State Expenditure Report," NASBO reported Medicaid represented the largest share of state budgets in the 2010 fiscal year due to increased Medicaid enrollment and spending resulting from the economic decline. Medicaid displaced elementary and secondary education as the largest component, a place it had held since the 2009 fiscal year. In the 2011 fiscal year, NASBO found that Medicaid continued to grow as a percentage of total state expenditures, representing 23.6 percent, while K-12 declined to 20.1 percent.
National Association of State Budget Officers. "State Expenditures Report: Examining Fiscal 2009-2011 State Spending." http://www.nasbo.org/sites/default/files/2010%20State%20Expenditure%20Report.pdf 2 The Council of State Governments.National Analysis: Medicaid Spending. January 2012. http://knowledgecenter.csg.org/drupal/system/files/BOS/medicaid_spending_national.pdf 3 Miller, Debra.States Face Medicaid Match Loss After Recovery Act Expires. The Book of the States 2011. The Council of State Governments. http://knowledgecenter.csg.org/drupal/content/states-face-medicaid-match-loss-after-recovery-act-expires-0
1

Table Notes: (a) Medicaid appropriations are "gross funded" -- federal funds are deposited directly to the state treasuries. (b) Inflation adjustment (1.0849) from Consumer Price Index, U.S. Bureau of Labor Statistics. Calculations by CSG. Table Sources: National Association of Budget Officers. "State Expenditures Report: Examining Fiscal 2009-2011 State Spending." http://www.nasbo.org/sites/default/files/2010%20State%20Expenditure%20Report.pdf; National Association of Budget Officers. "State Expenditures Report: FY 2008 State Spending." http://www.nasbo.org/sites/default/files/FY08%20State%20Expenditure%20Report.pdf; CSG calculations

MEDICAIDEEXPENDITURES oASotal State PERCENT Medicaid xpenditures as Percent f T OF TOTAL STATE EXPENDITURES, 2007-2011 Expenditures, 2007-2011
30 25 20 15 10 5 0 2007 2011

Na)onal Average

East Region

Midwest Region

South Region

West Region

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 MEDICAID EXPENDITURES BY STATE AND REGION

(In millions of dollars)
Medicaid expenditures as percent of total expenditures (all funds), 2007
20.9 17.2 12.5 30.2 18.8 18.1 25.9 20.0 28.7 30.7 23.8 18.3 22.7 27.1 21.9 18.0 18.6 21.7 22.2 18.7 14.7 23.8 20.9 13.9 21.6 12.3 19.9 21.7 21.1 20.3 19.9 19.9 35.6 26.6 18.1 22.4 28.9 16.5 14.5 11.6 23.2 9.2 22.5 19.7 10.9 10.0 21.7 17.6 16.0 18.6 15.9 16.0 19.1 9.2 17.6 16.9

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Medicaid expenditures as percent of total expenditures (all funds), 2011
23.6 27.2 16.2 28.6 21.6 20.2 25.2 21.9 29.1 31.1 24.7 26.6 24.8 28.9 24.4 19.3 18.6 24 25.1 16.5 14.6 23.2 23.2 17 23 25.3 20.5 28 20.5 22.8 23.5 22.6 36.3 22.1 18.5 19.9 28.1 26.3 16.9 13 23.7 9 28 24.2 19.4 15.9 25.6 15.7 18.7 20.2 14.6 14.3 24.4 7 21.7 19

State or other jurisdiction

General fund
$110,228 3,152 486 660 2,559 7,551 440 4,380 9,017 6,418 796 197 33,097 4,235 1,461 665 835 2,326 2,965 619 165 9,251 219 1,788 24,529 491 652 4,549 2,211 982 752 315 1,106 2,650 869 754 2,259 6,589 2,586 409 29,733 374 1,523 13,403 1,226 440 321 158 437 764 901 318 2,791 213 22,869 9,466

Federal funds
$167,930 0 490 1,342 2,775 0 580 4,554 19,867 9,441 848 556 37,678 5,977 3,117 1,470 1,310 5,227 3,060 889 326 2,355 420 2,835 26,986 3,107 2,297 8,291 4,472 3,107 4,018 2,577 4,002 6,152 2,143 3,062 4,567 12,373 2,456 1,547 66,946 656 4,436 19,418 1,296 616 713 510 700 1,941 1,924 984 2,887 239 36,320 16,902

Other state funds

$26,966 775 0 169 115 0 157 129 3,504 1,634 0 188 6,556 2,336 415 490 86 1,682 0 20 4 1,150 0 147 6,330 898 255 1,500 730 442 413 422 2,360 1,692 309 659 267 1,634 0 201 11,897 27 549 643 93 6 85 51 106 44 395 184 0 0 2,183 1,540

Total
$305,124 3,927 976 2,171 5,449 7,551 1,177 9,063 32,388 17,493 1,644 941 77,331 12,548 4,993 2,625 2,231 9,235 6,025 1,528 495 12,756 639 4,770 57,845 4,496 3,204 14,340 7,413 4,531 5,183 3,314 7,468 10,494 3,321 4,475 7,093 20,596 5,042 2,157 108,576 1,057 6,508 33,464 2,615 1,062 1,119 719 1,243 2,749 3,220 1,486 5,678 452 61,372 27,908

General fund
$110,672 4,466 481 439 2,005 10,440 395 4,111 6,296 5,523 806 177 35,139 3,341 1,292 403 790 1,440 3,156 507 225 10,777 267 1,413 23,611 345 635 3,978 1,731 911 658 168 1,531 2,466 960 726 2,152 7,887 2,977 307 27,432 373 1,290 12,573 1,269 606 299 152 487 539 918 258 3,825 226 22,815 10,242

Federal funds
$249,807 0 777 1,694 4,098 0 831 6,007 26,060 12,188 1,234 855 53,744 9,560 4,879 2,331 1,828 8,743 4,848 1,085 501 2,590 611 5,071 42,047 3,851 3,424 12,081 5,793 4,537 5,353 3,395 6,389 7,660 2,675 3,870 6,252 16,936 4,197 2,239 88,652 871 5,848 36,814 2,807 1,180 1,311 741 974 2,342 3,408 1,419 3,943 336 61,994 25,180

Other state funds

$38,092 1,127 0 205 558 0 145 136 4,669 1,716 7 253 8,816 3,320 432 843 125 1,821 61 21 2 598 0 787 8,010 1,086 119 3,721 520 360 1,088 901 1,050 1,172 457 522 275 58 0 240 11,569 14 1,044 5,573 1,435 0 194 72 135 115 557 238 141 0 9,518 3,945

Total
$398,571 5,593 1,258 2,338 6,661 10,440 1,371 10,254 37,025 19,427 2,047 1,285 97,699 16,221 6,603 3,577 2,743 12,004 8,065 1,613 728 13,965 878 7,271 73,668 5,282 4,178 19,780 8,044 5,808 7,099 4,464 8,970 11,298 4,092 5,118 8,679 24,881 7,174 2,786 127,653 1,258 8,182 54,960 5,511 1,786 1,804 965 1,596 2,996 4,883 1,915 7,909 562 94,327 39,367

Percent difference in spending 2007-2011, adjusted for inflation (b)

20.4% 31.3% 18.8% -0.7% 12.7% 27.4% 7.4% 4.3% 5.4% 2.4% 14.8% 25.9% 16.5% 19.2% 21.9% 25.6% 13.3% 19.8% 23.4% -2.7% 35.6% 0.9% 26.6% 40.5% 17.4% 8.3% 20.2% 27.1% 0.0% 18.2% 26.2% 24.2% 10.7% -0.8% 13.6% 5.4% 12.8% 11.4% 31.2% 19.1% 8.4% 9.7% 15.9% 51.4% 94.3% 55.0% 48.6% 23.7% 18.4% 0.5% 39.8% 18.8% 28.4% 14.6% 41.7% 30.0%

Difference in percent of total expenditures 20072011 (percentage points)

2.7 10.0 3.7 -1.6 2.8 2.1 -0.7 1.9 0.4 0.4 0.9 8.3 2 1.8 2.5 1.3 0.0 2.3 2.9 -2.2 -0.1 -0.6 2.3 3.1 1.4 13.0 0.6 6.3 -0.6 2.5 3.6 2.7 0.7 -4.5 0.4 -2.5 -0.8 9.8 2.4 1.4 0.5 -0.2 5.5 4.5 8.5 5.9 3.9 -1.9 2.7 1.6 -1.3 -1.7 5.3 -2.2 4.1 2.1

U.S. totals
East Connecticut Delaware Maine Maryland Massachusetts New Hampshire New Jersey New York Pennsylvania Rhode Island Vermont Regional Total Midwest Illinois Indiana Iowa Kansas Michigan Minnesota Nebraska North Dakota Ohio South Dakota Wisconsin Regional Total South Alabama Arkansas Florida Georgia Kentucky Louisiana Mississippi Missouri North Carolina Oklahoma South Carolina Tennessee Texas Virginia West Virginia Regional Total West Alaska Arizona California Colorado Hawaii Idaho Montana Nevada New Mexico Oregon Utah Washington Wyoming Regional Total Regional Total w/o CA

Debra Miller, CSG Director of Health Policy | dmiller@csg.org

A PRODUCT OF CAPITOL RESEARCH

SOUTH

THE COUNCIL OF STATE GOVERNMENTS | AUGUST 2012

THE BOOK OF THE STATES 2012 Facts & Figures

STATES MEDICAID SPENDING GROWING
States face a huge decision before 2014. In its June 2012 decision on the Affordable Care Act, the U.S. Supreme Court placed in states hands the decision whether to expand eligibility for Medicaid to 133 percent of the federal poverty level. Currently, states provide Medicaid coverage to some adults with eligible children setting state eligibility at various percentages less than the federal poverty level. Non-disabled adults without children are not eligible for Medicaid, under current rules. Data show that Medicaid expenditures have grown nationally between 2007 and 2011. Medicaid expenditures by states, as a percentage of overall budget expenditures, also have grown during that time. As state policymakers grapple with the decision regarding Medicaid eligibility expansion, they must consider whether increased Medicaid obligations will displace other budget priorities and whether states can sustain Medicaid budget growth, even with the favorable match rate for the expansion population currently in law. Louisiana and Mississippi also posted growth exceeding the regional average in the four-year period. Georgias Medicaid expenditures, adjusted for inflation, remained the same over the four-year period. North Carolina actually cut expenditures, saving 0.8 percent in 2011 compared to 2007. The state share of spending for Medicaid grew in all but four South region statesGeorgia, North Carolina, South Carolina and Tennesseewith the regional average of a 0.5 percentage point growth considerably lower than the national average growth of 2.7 percentage points. Alabama and Texas saw the proportion of state budgets expended for Medicaid increase significantly, up 13 percentage points in Alabama and 9.8 percentage points in Texas.

National Analysis
Nationally, state Medicaid expenditures grew 20.4 percent between 2007 and 2011. Growth in expenditures for Medicaid reflects increased enrollment driven by unemployment during and following the Great Recession. The federal stimulus package provided an enhanced federal Medicaid matching rate to states between 2008 and 2011; that enhanced match rate relieved some of the burden on states to provide increased general funds to Medicaid. This obligation, however, came roaring back to states in July 2011 when the enhanced federal Medicaid matching rates were discontinued. According to National Association of State Budget Officers state expenditure data, the share of total state budgets spent on Medicaid has increased from an average of 20.9 percent in 2007 to 23.6 in 2011, a 2.7 percentage point increase. Without very robust growth in overall state revenues, large growth in Medicaid spending crowds out new spending for other budget priorities.
35% 30% 25% 20% 15% 10% 5% 0% -5%

GROWTH iIN Medicaid Expenditures, Growth n MEDICAID EXPENDITURES, adjusted for INFLATION, 2007-2011 ADJUSTED FORina8on, 2007-2011

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MEDICAID EXPENDITURES AS Total State Medicaid Expenditures as Percent of PERCENT Expenditures, 2007-2011 OF TOTAL STATE EXPENDITURES, 2007-2011
40 35 30 25 20 15 10 5 0
R eg Al ion ab am Ar a ka ns a Flo s rid Ge a or Ke gia nt u Lo cky ui sia M iss na iss i M pp No is i rth sou C ri ar o Ok lina So lah ut h oma Ca r Te olin nn a es se e Te xa s W Virg es i t V nia irg in ia th

Regional Analysis
Medicaid expenditure growth in the South region, 8.4 percent from 2007 to 2011, was less than half the national average of 20.4 percent for the same four-year period. Within the South region, Virginia and Florida posted the largest expenditure growth of 31.2 and 27.1 percent, respectively.
1

Miller, Debra. States Face Medicaid Match Loss After Recovery Act Expires. The Book of the States 2011. The Council of State Governments. http://knowledgecenter.csg.org/drupal/content/states-face-medicaid-match-loss-after-recovery-act-expires-0 Table Notes: (a) Medicaid appropriations are "gross funded" -- federal funds are deposited directly to the state treasuries. (b) Inflation adjustment (1.0849) from Consumer Price Index, U.S. Bureau of Labor Statistics. Calculations by CSG. Table Sources: National Association of Budget Officers. "State Expenditures Report: Examining Fiscal 2009-2011 State Spending." http://www.nasbo.org/sites/default/files/2010%20State%20Expenditure%20Report.pdf; National Association of Budget Officers. "State Expenditures Report: FY 2008 State Spending." http://www.nasbo.org/sites/default/files/FY08%20State%20Expenditure%20Report.pdf; CSG calculations

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FOR MORE INFORMATION VISIT WWW.CSG.ORG/BOOKOFTHESTATES

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A PRODUCT OF CAPITOL RESEARCH

MIDWEST

THE COUNCIL OF STATE GOVERNMENTS | AUGUST 2012

THE BOOK OF THE STATES 2012 Facts & Figures

STATES MEDICAID SPENDING GROWING
States face a huge decision before 2014. In its June 2012 decision on the Affordable Care Act, the U.S. Supreme Court placed in states hands the decision whether to expand eligibility for Medicaid to 133 percent of the federal poverty level. Currently, states provide Medicaid coverage to some adults with eligible children setting state eligibility at various percentages less than the federal poverty level. Non-disabled adults without children are not eligible for Medicaid, under current rules. Data show that Medicaid expenditures have grown nationally between 2007 and 2011. Medicaid expenditures by states, as a percentage of overall budget expenditures, also have grown during that time. As state policymakers grapple with the decision regarding Medicaid eligibility expansion, they must consider whether increased Medicaid obligations will displace other budget priorities and whether states can sustain Medicaid budget growth, even with the favorable match rate for the expansion population currently in law. 35.6 percent growth over the four-year period. Spending for Medicaid in Nebraska fell 2.7 percent over the study period and Ohios spending grew just 0.9 percent. Seven Midwestern statesIllinois. Indiana, Iowa, Minnesota, North Dakota, South Dakota and Wisconsinhad Medicaid expenditure growth that exceeded the national average growth from 2007 to 2011. The state share of spending for Medicaid grew in all but three Midwestern statesNebraska, North Dakota and Ohio; the regional average growth of 1.4 percentage points was about half the national average growth of 2.7 percentage points.

Growth in Medicaid EXPENDITURES, GROWTH IN MEDICAID Expenditures, adjusted for na8on, 2 2007-2011 ADJUSTED FOR iINFLATION,007-2011
45% 40% 35% 30% 25% 20% 15% 10% 5% 0%
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National Analysis
Nationally, state Medicaid expenditures grew 20.4 percent between 2007 and 2011.Growth in expenditures for Medicaid reflects increased enrollment driven by unemployment during and following the Great Recession. The federal stimulus package provided an enhanced federal Medicaid matching rate to states between 2008 and 2011; that enhanced rate relieved some of the burden on states to provide increased general funds to Medicaid. This obligation, however, came roaring back to states in July 2011 when the enhanced federal Medicaid matching rates were discontinued.1 According to National Association of State Budget Officers state expenditure data, the share of total state budgets spent on Medicaid increased from an average of 20.9 percent in 2007 to 23.6 in 2011, a 2.7 percentage point increase. Without very robust growth in overall state revenues, large growth in Medicaid spending crowds out new spending for other budget priorities.

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MEDICAID EXPENDITURES AS PERCENT

Regional Analysis
Medicaid expenditure growth in the Midwest region, 17.4 percent from 2007 to 2011, was somewhat less than the national average of 20.4 percent for the same four-year period. Within the Midwest region, Wisconsin posted the largest expenditure growth of 40.5 percent, with North Dakota close behind at
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Miller, Debra. States Face Medicaid Match Loss After Recovery Act Expires. The Book of the States 2011. The Council of State Governments. http://knowledgecenter.csg.org/drupal/content/states-face-medicaid-match-loss-after-recovery-act-expires-0 Table Notes: (a) Medicaid appropriations are "gross funded" -- federal funds are deposited directly to the state treasuries. (b) Inflation adjustment (1.0849) from Consumer Price Index, U.S. Bureau of Labor Statistics. Calculations by CSG. Table Sources: National Association of Budget Officers. "State Expenditures Report: Examining Fiscal 2009-2011 State Spending." http://www.nasbo.org/sites/default/files/2010%20State%20Expenditure%20Report.pdf; National Association of Budget Officers. "State Expenditures Report: FY 2008 State Spending." http://www.nasbo.org/sites/default/files/FY08%20State%20Expenditure%20Report.pdf; CSG calculations

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FOR MORE INFORMATION VISIT WWW.CSG.ORG/BOOKOFTHESTATES

A PRODUCT OF CAPITOL RESEARCH

2007 2011

EAST

THE COUNCIL OF STATE GOVERNMENTS | AUGUST 2012

THE BOOK OF THE STATES 2012 Facts & Figures

STATES MEDICAID SPENDING GROWING
States face a huge decision before 2014. In its June 2012 decision on the Affordable Care Act, the U.S. Supreme Court placed in states hands the decision whether to expand eligibility for Medicaid to 133 percent of the federal poverty level. Currently, states provide Medicaid coverage to some adults with eligible children setting state eligibility at various percentages less than the federal poverty level. Non-disabled adults without children are not eligible for Medicaid, under current rules. Data show that Medicaid expenditures have grown nationally between 2007 and 2011. Medicaid expenditures by states, as a percentage of overall budget expenditures, also have grown during that time. As state policymakers grapple with the decision regarding Medicaid eligibility expansion, they must consider whether increased Medicaid obligations will displace other budget priorities and whether states can sustain Medicaid budget growth, even with the favorable match rate for the expansion population currently in law. in 2011 compared to 2007. Delaware, Massachusetts and Vermont all had significant Medicaid expenditure growth from 2007 to 2011, adjusted for inflation, at 31.3, 27.4 and 25.9 percent respectively. Those numbers exceeded both the national and East region averages16.5 percent growth for the East region and 20.4 percent nationally. Every Eastern state except for Maine and New Hampshire increased the share of their state budgets devoted to Medicaid program spending between 2007 and 2011; that is consistent with the national and East regional trends. Connecticut posted the largest regional growth in the proportion of all state expenditures for Medicaid; it grew 10 percentage points, from 17.2 percent to 27.2 percent of expenditures. Vermonts share of spending for Medicaid rose 8.3 percentage points.

National Analysis
Nationally, state Medicaid expenditures grew 20.4 percent between 2007 and 2011. Growth in expenditures for Medicaid reflects increased enrollment driven by unemployment during and following the Great Recession. The federal stimulus package provided an enhanced federal Medicaid matching rate to states between 2008 and 2011; that enhanced match rate relieved some of the burden on states to provide increased general funds to Medicaid. This obligation, however, came roaring back to states in July 2011 when the enhanced federal Medicaid matching rates were discontinued. According to National Association of State Budget Officers state expenditure data, the share of total state budgets spent on Medicaid has increased from an average of 20.9 percent in 2007 to 23.6 in 2011, a 2.7 percentage point increase. Without very robust growth in overall state revenues, large growth in Medicaid spending crowds out new spending for other budget priorities.
35% 30% 25% 20% 15% 10% 5% 0% -5%

Growth in MEDICAID EXPENDITURES, GROWTH IN Medicaid Expenditures, adjusted for INFLATION, 2007-2011 ADJUSTED FORina8on, 2007-2011

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Regional Analysis
Medicaid expenditure growth in the East region, 16.5 percent from 2007 to 2011, was less than the national average of 20.4 percent for the same four-year period. Within the East region, Connecticut posted the largest expenditure growth of 31.3 percent, while Maine actually cut expenditures by 0.7 percent, the only state in the East to reduce Medicaid spending
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A PRODUCT OF CAPITOL RESEARCH

WEST

THE COUNCIL OF STATE GOVERNMENTS | AUGUST 2012

THE BOOK OF THE STATES 2012 Facts & Figures

STATES MEDICAID SPENDING GROWING
States face a huge decision before 2014. In its June 2012 decision on the Affordable Care Act, the U.S. Supreme Court placed in states hands the decision whether to expand eligibility for Medicaid to 133 percent of the federal poverty level. Currently, states provide Medicaid coverage to some adults with eligible children setting state eligibility at various percentages less than the federal poverty level. Non-disabled adults without children are not eligible for Medicaid, under current rules. Data show that Medicaid expenditures have grown nationally between 2007 and 2011. Medicaid expenditures by states, as a percentage of overall budget expenditures, also have grown during that time. As state policymakers grapple with the decision regarding Medicaid eligibility expansion, they must consider whether increased Medicaid obligations will displace other budget priorities and whether states can sustain Medicaid budget growth, even with the favorable match rate for the expansion population currently in law. New Mexicos Medicaid spending stayed about the same, growing only 0.5 percent over the four-year period. Alaskas growth, at 9.7 percent, was less than one-quarter of the regional average. Medicaid expenditures in Arizona, Nevada, Utah and Wyoming also grew at slower rates than the West region average and the national average. The state share of spending for Medicaid grew in all but five West region statesAlaska, Montana, Oregon, Utah and Wyomingwith the regional average of a 4.1 percentage point growth almost twice the national average growth of 2.7 percentage points. In other words, Western states were significantly increasing the share of state budget spending for Medicaid in the four-year analysis period. For instance, Colorado increased Medicaid spending from 10.9 percent of budget expenditures to 19.4 percent. Even with the growth of Medicaid spending in the West, the region spends a lower percentage of state budgets on Medicaid than the nation21.7 percent for the region including California, and 19 percent without California in 2011, compared to 23.6 percent for the nation as a whole.

National Analysis
Nationally, state Medicaid expenditures grew 20.4 percent between 2007 and 2011. Growth in expenditures for Medicaid reflects increased enrollment driven by unemployment during and following the Great Recession. The federal stimulus package provided an enhanced federal Medicaid matching rate to states between 2008 and 2011; that enhanced match rate relieved some of the burden on states to provide increased general funds to Medicaid. This obligation, however, came roaring back to states in July 2011 when the enhanced federal Medicaid matching rates were discontinued. According to National Association of State Budget Officers state expenditure data, the share of total state budgets spent on Medicaid has increased from an average of 20.9 percent in 2007 to 23.6 in 2011, a 2.7 percentage point increase. Without very robust growth in overall state revenues, large growth in Medicaid spending crowds out new spending for other budget priorities.

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Growth n MEDICAID EXPENDITURES, GROWTH iIN Medicaid Expenditures, adjusted for ina8on, 2007-2011 ADJUSTED FOR INFLATION, 2007-2011

Regional Analysis
Medicaid expenditure growth in the West region, 41.7 percent from 2007 to 2011, was about twice the national average of 20.4 percent for the same four-year period. Within the West region, Colorado posted the largest expenditure growth of 94.3 percent, almost doubling spending in the four-year period. California, Hawaii and Idaho all posted growth higher than the regional average.
1

Miller, Debra. States Face Medicaid Match Loss After Recovery Act Expires. The Book of the States 2011. The Council of State Governments. http://knowledgecenter.csg.org/drupal/content/states-face-medicaid-match-loss-afterrecovery-act-expires-0 Table Notes: (a) Medicaid appropriations are "gross funded" -- federal funds are deposited directly to the state treasuries. (b) Inflation adjustment (1.0849) from Consumer Price Index, U.S. Bureau of Labor Statistics. Calculations by CSG. Table Sources: National Association of Budget Officers. "State Expenditures Report: Examining Fiscal 2009-2011 State Spending." http://www.nasbo.org/sites/default/files/2010%20State%20Expenditure%20Report.pdf; National Association of Budget Officers. "State Expenditures Report: FY 2008 State Spending." http://www.nasbo.org/sites/default/files/FY08%20State%20Expenditure%20Report.pdf; CSG calculations
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FOR MORE INFORMATION VISIT WWW.CSG.ORG/BOOKOFTHESTATES

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30 25 20 15 10 5 0

OF TOTAL STATE EXPENDITURES, 2007-2011

2007 2011

Medicaid Expenditures as Percent of PERCENT MEDICAID EXPENDITURES AS Total State Expenditures, 2007-2011

A PRODUCT OF CAPITOL RESEARCH