Medicaid by State in 2016: I’ll Take What I Can Get

Some years go the Medicaid Statistical Information System (MSIS) State Datamart, which I once used to compare New York State with the U.S. average and adjacent states with regard to Medicaid expenditures and beneficiaries, was shut down. The most recent data I tabulated was for 2011.   Now, the Centers for Medicare & Medicaid has released their new system, T (Transformed) MSIS.

https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/index.html

I spent a long time looking around the site to try to find the data I once used, but was unable. But I was able to find some more recent Medicaid expenditure data by state and type of service here…

https://www.medicaid.gov/medicaid/financing-and-reimbursement/state-expenditure-reporting/expenditure-reports/index.html

Including 2016. And was able to get some limited data on spending per enrollee from a secondary source.

https://www.kff.org/state-category/medicaid-chip/

So after three and half years, I’ve decided to write an updated, if limited, post about how New York State’s Medicaid expenditures compare with the U.S. average and adjacent states.

My prior analysis was written about in a three-post sequence comparing Medicaid in 2011 with 2001. The first post compared total expenditures and beneficiaries.

https://larrylittlefield.wordpress.com/2014/09/04/medicaid-by-state-in-2001-and-2011/

With the next two comparing Medicaid expenditures, beneficiaries and expenditures per beneficiary by type of service…

https://larrylittlefield.wordpress.com/2014/09/04/medicaid-by-state-in-2001-and-2011/

And by age of beneficiary.

https://larrylittlefield.wordpress.com/2014/09/18/medicaid-by-state-and-age-in-2001-and-2011/

The data I was able to get for FY 2016 was expenditure by service category alone.   After looking around I was unable to find any data on the number of beneficiaries, just on enrollment, and just enrollment by month rather than over the course of a year at that. Enrollment is not a statistic I’m familiar with, and I was unable to find a glossary, so I decided to stick with the dollars, which you can see in this spreadsheet.

Medicaid NY-NE-US-2016

The data shows that New York State’s Medicaid program remains relatively expensive overall.

Chart1

In 2015, according to Bureau of Economic Analysis data, New York State accounted for 6.2% of the nation’s population, and its residents accounted for 7.4% of U.S. personal income. The difference is due to an above average per capita income for New York. In 2016, according to the American Community Survey from the U.S. Census Bureau, it accounted for 6.4% of the U.S. population in poverty.   The U.S. poverty rate was 14.0%, but New York’s rate was slightly higher at 14.7%.

New York State, however, accounted for 11.0% of total U.S. Medicaid expenditures, well above its 6.2% of the nation’s population, 6.4% of its poor people, or 7.4% of its personal income.

The high cost of living, and associated pay levels for those working in the health care industry, may push up the cost of health care in New York State, or at least in Downstate New York.   And New Yorkers tend to support more public spending for more services for the poor and others than do residents of most other states. These factors, however, are also present in the Northeastern states adjacent to New York – New Jersey, Pennsylvania, Vermont, Massachusetts, and Connecticut.

These “Adjacent States” in total accounted for 10.2% of the U.S. population, but also accounted for 12.1% of U.S. personal income due to above average per capita income, but just 8.1% of U.S. poor people due to below average poverty. Higher average income and a lower percent in poverty would logically go together; New York State, with economically diverse population, is an exception.

The Adjacent States accounted for 12.2% of total U.S. Medicaid expenditures, above their 10.2% of the total U.S. population and 8.1% of the U.S. poor population, but about the same as their share of U.S. personal income.

Medicaid spending, therefore, accounts for a much higher than average share of the personal income of New York State residents (all of us) and an average share of the personal income of the residents of adjacent states.

The cost of Medicaid is split among the federal, state and (in New York) local governments. At the national level the federal government pays a higher percent of Medicaid costs in states with lower per capita incomes, with most of the Northeast at the minimum 50 percent federal share for the basic Medicaid Assistance Program the (for some parts of the program added later the federal share is higher).

Chart2

Overall, New York State residents pay more into the federal government than they get out of it.

Click to access federal-budget-fiscal-year-2016.pdf

But Medicaid is an exception – though not to the extent widely believed, thanks to the low federal matching share.   In 2016 New York State residents and businesses accounted for 8.0% of total federal tax collections, according to the Tax Policy Center, but New York State accounted for 9.6% of total federal Medicaid funding.

The Adjacent States are a better deal for other parts of the country, due to their lower poverty rate. They collectively account for 13.7% of federal tax payments but just 11.3% of federal Medicaid funding.

New Yorkers bear a high state and local tax burden to pay for Medicaid. With just 6.2% of the U.S. population and 7.4% of its personal income, New York State accounted for 13.5% of state and local government funding for Medicaid. One consequence is high taxes. New York State accounted for 11.0% of total U.S. state and local government tax collections.   Another consequence is lower spending on other things, since New York’s share of U.S. state and local Medicaid funding is higher than its share of state and local tax revenues.   New York’s public school expenditures are also relatively high.

Thanks to their low federal matching share, the Adjacent States account for 13.8% of total state government Medicaid funding, despite accounting for just 12.2% of expenditures.   Their share of state and local government tax collections, at 12.4%, is only slightly higher than their share of personal income, at 12.1%.   So in the Adjacent States higher state Medicaid funding had been offset not so much by higher taxes, but by lower spending on other things. Unfortunately two of those other things were infrastructure investment and taxpayer pension contributions, leading to infrastructure and fiscal crises in virtually all of these states.

Chart3

When I first starting compiling this data I noted that New York State was near the top in total Medicaid spending per beneficiary, and in spending on services for hospital and services for seniors such as nursing homes and home health care, and yet was near the bottom in spending on physicians’ services and other preventive care.

Today these differences are obscured by the fact that nearly half of all current Medicaid expenditures are not directly on health services at all, but rather on health insurance via the Medicaid Managed Care program, Medicare premium payments for “dual eligibles,” and Obamacare and other health insurance payments.   Late to the trend of, in effect, contracting out Medicaid, New York State has since caught up. New York accounted for 11.0% of total U.S. Medicaid expenditures in 2016, and 10.4% of total Medicaid expenditures on insurance.

Given that caveat, New York State’s relative expenditures by category remain mostly intact.   With 6.4% of the nation’s poor people overall, it accounted for 11.0% of U.S. Medicaid expenditures overall but just 8.2% of expenditures on Physicians, Clinics, Outpatient Hospital Services and the like, and just 6.4% of expenditures on Prescription Drugs and Lab and Radiology services.

The Democratic Party, politically dominant in New York, doesn’t tend to over-fund these services as a matter of jobs and political patronage. In fact just the opposite – the pharmaceutical companies are a useful punching bag for Democratic politicians.   So expenditures in these categories tend to represent just what is required for actual health care, or less.

On the other hand New York accounts for 11.4% of total U.S. Medicaid expenditures on Inpatient Hospital Services; 14.1% of total expenditures on Nursing Homes, Intermediate are Facilities, and Hospices combined; and 15.3% of expenditures on Mental Health Facility services, all well above the 11.0% overall.

New York has traditionally provided more services than other states for the mentally ill, and better services for seniors. Many other states send their indigent to benefit from New York’s hospitals, on New York taxpayers’ dimes.   And these industries and their unions are politically influential.

New York accounted for 7.6% of U.S. seniors in poverty, compared with 14.1% of Medicaid expenditures on Nursing Homes, Intermediate are Facilities, and Hospices; and 11.1% of U.S. expenditures on at-home Home Health Care, Personal Care, Home and Community-Based Care, and All Inclusive Elderly Care.   New York State’s share of U.S spending in the latter category was once much higher.   Back in the 1990s, when I first started compiling this data, New York State accounted for 90 percent of U.S. Medicaid “Personal Care” expenditures and a large share of Medicaid Home Health Care expenditures as well. It seems that the explosion of home health care employment observed in New York City is not just a New York City thing.

One place the cost of Medicaid services for seniors is certainly increasing is the Adjacent States.    Booming with suburban development 70 years ago, these states are now aging rapidly as the suburbs fill with retired empty nesters and young workers move away.   In some Northeastern states cities that young people are flocking to, such as New York and Boston, comprise a high share of the total state population, but in others less so.

With 10.2% of the total U.S. population and just 9.3% of its poor seniors, the Adjacent States accounted for 17.4% of Medicaid expenditures on Nursing Homes, Intermediate are Facilities, and Hospices; and also 17.4% of U.S. expenditures on at-home Home Health Care, Personal Care, Home and Community-Based Care, and All Inclusive Elderly Care.

That is a large burden to carry with just 12.1% of U.S. personal income and a low federal matching share. A burden that seems set to rise, exacerbating the burdens of underfunded and retroactively enriched pensions and a deteriorating infrastructure. Upstate New York and the Downstate New York Suburbs are in a similar position, but they use the state government to shift that burden to New York City as I described here.

https://larrylittlefield.wordpress.com/2017/05/20/medicaid-the-rest-of-new-york-state-re-declares-war-on-new-york-city/

The fiscal burdens of the “tax cut” generations are likely to exacerbate nasty political fights over money, with the selfish and entitled seeking people and public services to be made worse off to maintain their own benefits. Particularly while members of Generation Greed continue to control our public and private institutions. Particularly given the decline of the family associated with that same generation, as I anticipated in this post.

https://larrylittlefield.wordpress.com/2014/08/13/generation-greed-and-the-family/

And let’s just say the solution some were proposing one and two decades ago, increased reliance on private long term care insurance, hasn’t worked out so well, and will likely disappear or become so expensive and skimpy it is not worth having, as the stunning recent write-off by General Electric as a result of its foray in to long term care insurance shows.

https://www.bloomberg.com/view/articles/2018-01-29/what-s-bad-for-ge-will-be-worse-for-america

The Adjacent States also accounted for 18.8% of U.S. Medicaid Mental Health Facility expenditures.   These states, like New York, have long provided more help than the rest of the country for the mentally ill.   With 14.5% of the U.S. population in poverty, New York plus the adjacent states accounted for 34.1% of total Medicaid expenditures on the mentally ill.

Like New York, Philadelphia and Boston have large, politically influential non-profit hospital sectors.   And yet the Adjacent States accounted for just 8.7% of total U.S. Medicaid expenditures on Inpatient Hospital expenditures in FY 2016. Perhaps people from other places are less likely to use Pennsylvania and Massachusetts hospitals, half on those states’ taxpayers’ dimes. Or perhaps Medicaid beneficiaries in these states are healthier. They accounted for 10.9% of expenditures on Physicians, Clinics, Outpatient Hospital Services and the like, slightly lower than their 12.2% of total U.S. Medicaid expenditures.

_______________________________________________________________________________________

A second tabulation I have previously done was Medicaid expenditures per beneficiary by age group. I couldn’t find data on expenditures or beneficiaries by age, but I was able to find data for 2014 on Medicaid expenditures per enrollee by enrollment group – children, adult, disabled, aged.

It’s from a secondary source, and I prefer to avoid such sources, because who knows the assumptions and biases that might be in it?   But as data seems to shrink away, and Generation Greed’s values – there is no right and wrong, factually correct and incorrect, just winners and losers and feelings about what we want to hear — infest every aspect of society, who is to say that original source data is accurate either? So here is what I found.

Kaiser Medicaid 2014 Enrolee Type

The data is from the J. Kasier Family Foundation.

https://www.kff.org/state-category/medicaid-chip/

“KFF estimates based on analysis of data from the 2014 Medicaid Statistical Information System (MSIS) and Urban Institute estimates from CMS-64 reports. MSIS spending was adjusted to CMS-64 spending to account for MSIS undercounts of spending and missing quarters of data.”

“Adjustments vary across states, and some adjustments were made for the following states: Alabama, Alaska, Colorado, Delaware, District of Columbia, Florida, Illinois, Kansas, Kentucky, Maine, Maryland, Montana, Nevada, New Hampshire, New Mexico, North Carolina, North Dakota, Rhode Island, South Carolina, Texas, and Wisconsin. Due to these adjustments, spending estimates here may not match other analysis based on the MSIS data or state’s own reporting systems.”

Glad to NOT see New York State on that list. As I noted, in 2011 only 45 states had data good enough to included in MSIS, and for 2012 it was so few I didn’t bother to compile it.

Perhaps the sort of simple tabulations of data that used to be available in the MSIS state data cube will re-appear as T-MSIS rolls out.   I’ll look into that in the next year or two. For now, however, this is what we have.

Chart4

The data shows that New York States average Medicaid expenditure per enrollee, at $7,806, was 36.1% higher than the U.S. average of $5,736.   Not as big a gap as I was able to calculate for 2011 and prior years.   In 2011, according to MSIS data I was able to use, New York State’s average Medicaid expenditure per beneficiary, at $9,613, was 82.3% higher than the average for the 45 states that had reported data to MSIS, at $5,316.   In 2001, New York State spent $7,725 per Medicaid beneficiary, 91.4% higher than the U.S. average of $4,037.

The most optimistic take on this is that New York State has done a great job, relative to the rest of the country, in getting New Yorkers enrolled in Medicaid insurance even if they don’t require health care in a given year, and therefore don’t qualify as beneficiaries. Thus bringing the average expenditure per enrollee down.

In any event, whereas all prior analyses by everyone using the data once made available had showed New York State’s Medicaid expenditures per beneficiary to be far higher than the adjacent Northeastern states, the new data produced by these third parties show that not to be the case.   The $7,806 in total Medicaid expenditures per enrollee for New York State was lower than Pennsylvania at $8,760, and only slightly higher than Massachusetts at $7,458 and Connecticut at $7,704, though still far higher than the West Coast states. Only someone who has been looking at this data for decades would know things were once different.

Either the reality – or what people can see of it – has changed substantially.

Chart5

Data on expenditures per enrollee by enrollment group, however, show that New York’s past priorities by age remained intact through 2014.

Even though many of New York State’s child Medicaid recipients are located in high-cost New York City, the state’s expenditures per Child enrollee was just $2,627, only 1.9% higher than the U.S. average of $2,577.   Of course New York’s poor children are, in fact, poor, and many are immigrants or minorities, not the kind of people who count for much in “progressive” New York.   Or at least that’s the assertion I made when I found that New York’s spending per beneficiary on children was only average. Now that the denominator is enrollment, it is possible that spending per enrollee is only average because New York has signed up many healthy children for Medicaid relative to other places.

New York State’s Medicaid expenditure level on Adults was $4,453, 35.8% higher than the U.S. average of $3,278.   New York’s expenditure on the Disabled was $24,905 per enrollee, 47.7% higher than the U.S. average of $16,859. And its expenditure on the Aged was $20,888 per enrollee, 59.9% higher than the U.S. average of $13,063.   This matches up with I found in 2011 and earlier with regard to New York’s relative spending by age group.

Chart8

What is different is that in the Kaiser data per enrollee the Adjacent States are much more like New York State than in the data previously available, although New York’s Medicaid expenditure per child is still lower than most of them, and its expenditure per aged or disabled enrollee is still higher than any of them.

Hopefully a part of a compendium based on the 2017 Census of Governments, if it comes off and the data comes out in a usable form, I’ll be able to provide a more detailed discussion of New York’s Medicaid program, if more data is available.