Nebraska legislators have taken a thoughtful approach to the Affordable Care Act, carefully reviewing the evidence and ultimately declining to expand Medicaid to a new class of able-bodied adults under the law. Nevertheless, a small group of legislators lobby their colleagues each year to expand the program. The latest proposal, offered by Senator John McCollister, would copy the expansion models used by Arkansas and Iowa, homes of the highest profile “alternative” expansion models.
Under this approach, able-bodied adults receive regular Medicaid benefits through private health insurance plans sold on the Exchange, rather than through traditional Medicaid managed care. But these expansions have been unmitigated disasters and replicating the results in Nebraska would move the state backwards.
This new approach to Medicaid expansion is unaffordable and unpredictable, pushes adults out of private insurance and into taxpayer-funded welfare, puts the truly needy on the chopping block, discourages work, and shrinks the economy. So it should be no surprise that, last year, Iowa policymakers scrapped the model entirely and Arkansas enacted legislation to repeal the expansion altogether at the end of 2016. Nebraska policymakers should learn from these mistakes, not repeat them.
Arkansas’ Expansion Model Is Unaffordable
The basic mechanics of Arkansas’ Medicaid expansion model are simple: the state delivers Medicaid benefits through qualified health plans (QHPs) sold on the Exchange, instead of delivering those benefits through Medicaid managed care organizations or the fee-for-service Medicaid system. But the cost of expanding Medicaid through QHPs is far higher than the cost of traditional Medicaid expansion.
In January 2015, Senator Kathy Campbell introduced Legislative Bill 472, which would have expanded Medicaid under the Affordable Care Act.1 Under LB 472, individuals below the poverty line would receive coverage through traditional Medicaid, while those above the poverty line would have received Medicaid benefits through QHPs.2 The Nebraska Department of Health and Human Services contracted with actuaries from Milliman to analyze the impact of LB 472.3
While conducting its analysis, the state’s actuaries determined that using QHPs to deliver Medicaid benefits would increase per-person costs by 94 percent in fiscal year 2017.4 By fiscal year 2021, the cost difference between delivering benefits through QHPs and through traditional Medicaid is expected to reach 150 percent.5
According to the state’s actuaries, LB 472 would increase costs by nearly $950 million between fiscal years 2017 and 2021.6
FIGURE 1: Qualified Health Plans cost 94% more than traditional Medicaid
Source: Nebraska Department of Health and Human Services
But this assumed that fewer than one quarter of Medicaid expansion enrollees—only those with incomes above the poverty line—would be covered by QHPs. Under the latest Medicaid expansion proposal, most new enrollees would receive QHP coverage, increasing the total costs even more.
Based on the available data, it appears that expanding Medicaid through an Arkansas model would increase expansion costs by $1.9 billion over the next five fiscal years.8 The state share of those costs could be expected to increase by $136 million over that same time period, an increase of more than 84 percent.9
A recent evaluation by the Government Accountability Office revealed similar results in Arkansas. According to the GAO, Arkansas’ Medicaid expansion model will cost taxpayers nearly $800 million more in its first three years than traditional Medicaid expansion would have cost.10
But this was known prior to expanding Medicaid in 2013. The state’s Medicaid director at the time admitted in internal e-mails that he expected costs to be higher in the early years of the program.11
“We do expect the gross costs [of the Private Option] to be higher than expanding traditional Medicaid in the first years of the expansion.”
–Andy Allison, former Arkansas Medicaid director
Expansion Costs Are Unpredictable
If higher costs aren’t bad enough, Arkansas’ Medicaid expansion model also brings with it new budget uncertainties. Under the Arkansas model, able-bodied adults can choose any Silver-tier plan offered on the Exchange.12 But the prices of those plans vary greatly, even within the same regions.13 In Nebraska, the difference in premiums between the cheapest and most expensive Silver plans varies by up to 58 percent.14 Because enrollees have no financial incentive to choose less expensive options, taxpayers could see the more expensive plans—which often come with better provider networks—dominate the program.
Making matters worse, premiums for these Nebraska Silver plans have skyrocketed over the last few years, leaving taxpayers with little certainty about future costs. Premiums for the benchmark Silver plan have risen 32 percent since 2014, with higher increases expected when the Affordable Care Act’s temporary risk corridor and reinsurance programs go away in 2017.15-16-17-18
Blue Cross Blue Shield, the largest insurer in the state, hiked premiums by an average of 20 percent in 2015 and is hiking them another 15 percent for next year.19-20 Likewise, Coventry is increasing premiums by an average of nearly 22 percent next year.21
FIGURE 2: An Arkansas-style expansion would cost $1.9 billion more
Source: Author’s calculations
FIGURE 3: Premiums vary widely by plan choice in Nebraska
Source: U.S. Department of Health and Human Services
Unpredictable premiums have already caused problems in both Arkansas and Iowa. Despite hopes of “competition,” Iowa’s Medicaid expansion waiver attracted just two insurance carriers—Coventry and CoOportunity Health.22 But both insurers eventually stopped enrolling new able-bodied adults under the waiver. CoOportunity Health recorded a net operating loss of $163 million in 2014, blaming the Medicaid expansion as a primary cause of its financial tailspin.23
In order to make up for these losses, CoOportunity hiked premiums by an average of 21 percent and dropped out of the program entirely at the end of 2014.24 The state stepped in and took over the carrier, but by then it was too late—CoOportunity went insolvent in February 2015.25
CoOportunity’s departure left just one participating carrier, but Coventry was facing financial turmoil of its own. Even after hiking premiums by an average of more than 19 percent in 2015, the insurer announced that was experiencing significant financial burdens caused by the Medicaid expansion and was on the verge of dropping out.26 Eventually, Coventry stopped accepting new Medicaid expansion enrollees and Iowa officials were forced to scrap its Arkansas-style expansion waiver altogether.27
Likewise, Arkansas’ Medicaid expansion costs have been far higher than expected, leaving a new sense of uncertainty over future costs. Documents prepared by state officials a few months prior to expanding Medicaid predicted that these new enrollees would cost just $3,900 per year to cover on average.28 Those estimates were later increased to more than $5,200 for those enrolled in QHPs in fiscal year 2014.29 But actual costs for this population averaged more than $5,900 per year in 2014, amounting to nearly $32 million in cost overruns when compared to the updated projections.30
By the end of fiscal year 2015—18 months after the program initially launched—cost overruns had reached nearly $80 million.31 This does not account for additional cost overruns associated with higher than expected enrollment, which also occurred.
FIGURE 4: Premiums for the benchmark Silver plan have risen 32% since 2014
Source: U.S. Department of Health and Human Services
FIGURE 5: Arkansas’ Medicaid expansion is more expensive than expected
Source: Arkansas Department of Human Services
Enrollment Is Unpredictable
If Nebraska opts into Medicaid expansion, the state will face more than simply higher per-person costs—it is also likely to see more able-bodied adults enrolling in the program than ever imagined. Arkansas officials initially predicted that no more than 215,000 able-bodied adults would ever enroll in its Medicaid expansion.32 By the end of the first year, however, more than 230,000 people had enrolled in the expansion.33 Within 18 months, enrollment hit nearly 300,000 adults, far more than the state estimated would ever even be eligible.34-35 As a result, more than 41 percent of all Arkansans are on Medicaid, making Arkansas one of the most Medicaid-dependent states in the nation.36
Nebraska’s actuaries now estimate that a traditional Medicaid expansion would add 119,000 able-bodied adults to the program.37 But expanding through an Arkansas or Iowa-style waiver could increase that number by another 10,000 adults.38
But Nebraska’s enrollment overruns could be even worse, as these projections have proven to be ever-moving targets for actuaries. In 2013, for example, Milliman projected that Medicaid expansion enrollment in Nebraska would ultimately top out at fewer than 111,000 enrollees in 2020.39 Estimated enrollment was revised to more than 113,000 in 2014 and then jumped again to 127,000 in 2015.40-41 Even these estimates may be low, as other states have already exceeded their maximum enrollment projections by an average of more than 60 percent.42
Arkansas’ Model Crowds Out Private Insurance
One key driver of over-enrollment is the result of the crowding out private coverage. States that opt into Medicaid expansion under the Affordable Care Act create new incentives for able-bodied adults to abandon private insurance in exchange for taxpayer-funded welfare. Worse yet, it also moves thousands of individuals currently receiving coverage through the Exchange into the Medicaid program.
This phenomenon has played out in several past expansions including able-bodied adults and is playing out in others today.43 But the effect is even worse in an Arkansas-style expansion, where able-bodied adults are allowed to keep private coverage—either through their employer or a QHP—and simply shift the cost to taxpayers.
According to Nebraska’s actuaries, just 42 percent of those expected to sign up for Medicaid expansion would come from the ranks of the uninsured.44 This means that a whopping 58 percent of new enrollees either already have private insurance or are currently eligible for subsidies on the Exchange.45 Although any Medicaid expansion would cause crowd out, Nebraska’s actuaries estimate that an Arkansas-style expansion would actually increase the number of adults with employer-sponsored insurance who join Medicaid by an alarming 25 percent.46
FIGURE 6: An Arkansas-style expansion would increase enrollment
Source: Nebraska Department of Health and Human Services
FIGURE 7: Projected Medicaid expansion enrollment has risen 15% since 2013
Source: Nebraska Department of Health and Human Services
Arkansas’ Expansion Model Hurts the Truly Vulnerable
Expanding Medicaid under the Affordable Care Act would fundamentally transform the purpose of Nebraska’s Medicaid program. Medicaid has historically been reserved for particularly vulnerable populations, including poor children, pregnant women, seniors, and individuals with disabilities. But Medicaid expansion would change that, extending Medicaid benefits to an entirely new class of able-bodied adults who have no dependent children. Worse yet, Arkansas’ expansion model would prioritize these able-bodied adults over the truly needy.
Under the Arkansas model, expansion enrollees would receive their benefits through QHPs—private insurance plans with higher reimbursement rates—while the most vulnerable continue to receive benefits through traditional Medicaid. This would create perverse incentives for medical providers to accept more able-bodied adults in the expansion population, while the truly needy trapped in Medicaid continue to struggle for access to care.
If that weren’t bad enough, the Affordable Care Act creates its own perverse incentives to prioritize able-bodied adults over the truly needy. Under the law, the federal government reimburses Nebraska for 51 percent of the cost to provide Medicaid to the truly needy.47 But the federal government will cover 95 percent of the cost to provide Medicaid to this new class of able-bodied adults in 2017, ratcheting down to 90 percent thereafter.48
But when Medicaid costs run over-budget, as they have done in states that have opted into the expansion, state lawmakers must find the extra funding somewhere, either through higher taxes or spending cuts. Lawmakers would have an incentive to cut from the truly needy first because they would save just 5 cents out of every dollar cut from the Medicaid expansion budget, while they could save nearly 49 cents out of every dollar cut from services and benefits provided to the truly needy.
Vulnerable patients in states that previously expanded Medicaid have already faced critical cuts to services. Arizona, for example, eliminated coverage for heart, liver, lung, pancreas, and bone marrow transplants after an earlier Medicaid expansion cost taxpayers nearly four times what was expected.49 With the added budgetary pressure and perverse incentives that the Affordable Care Act’s new funding formula creates, it would be only a matter of time before these difficult choices were thrust upon Nebraska policymakers.
FIGURE 8: Medicaid expansion would crowd out private coverage
Source: Nebraska Department of Health and Human Services
FIGURE 9: Federal funding creates perverse incentives for state lawmakers
Source: Author's Calculations
Medicaid Expansion Would Discourage Work and Shrink The Economy
Expanding Medicaid under the Affordable Care Act would also create a massive new welfare cliff, trapping more Nebraskans in poverty and government dependency.
Under expansion, an able-bodied adult earning just below 138 percent of the federal poverty level would be eligible for taxpayer-funded Medicaid coverage, with total out-of-pocket costs capped at just $812 per year.50
But earning one more dollar would mean leaving Medicaid eligibility and facing a massive increase in potential costs on the Exchange. After subsidies, these individuals would owe premiums of more than $535 per year and face up to $2,250 in other out-of-pocket costs if selecting the benchmark Silver plan. Altogether, moving from Medicaid to the Exchange would leave these adults nearly $2,000 worse off.
This new welfare cliff is sure to discourage work. A comprehensive study released by the National Bureau of Economic Research, for example, found that past Medicaid expansions to able-bodied, childless adults reduced employment, depressed earnings, reduced labor force participation, and slowed the economy.51 In Nebraska, this means Medicaid expansion could cause nearly 14,000 able-bodied adults could leave the labor force entirely, with many more reducing their hours or shifting to part-time work.52
The Congressional Budget Office estimates that Medicaid expansion will reduce employment, earnings, and economic activity overall.53But several Medicaid expansion supporters nevertheless promise that expansion will spur economic activity and drive employment growth. Despite those promises, an analysis of government data reveals that states that have expanded Medicaid have actually had slower job growth than states that have not.54-55-56-57 In states that expanded Medicaid, for example, employment has risen by an average of 1.85 percent since December 2013, compared to 2.04 percent in states that opted out of expansion.58
As a result, states that are relying on new tax revenue from the promised job growth are now in dire fiscal straights. Kentucky, for example, estimated that Medicaid expansion would create 40,000 new jobs, which in turn would generate $1.1 billion in new state and local taxes.59 These new taxes were supposed to help offset nearly three-quarters of the state’s share of expansion costs.60 But the new jobs and revenues never materialized.61 Instead of adding the thousands of jobs supporters promised Medicaid expansion would create, Kentucky hospitals actually cut nearly 3,000 jobs in 2014.62
FIGURE 10: Medicaid expansion creates a massive welfare cliff
Source: Author’s calculations
FIGURE 11: Employment is growing faster in non-expansion states
Source: U.S. Department of Labor
Medicaid Expansion Won’t Save Nebraska Hospitals
Medicaid expansion advocates frequently insist that hospitals—especially rural hospitals—will close without expansion. Policymakers should not expect Medicaid expansion to be a cure for the financial difficulties faced by some rural hospitals. Rural hospitals are closing even in states that expanded Medicaid, including Arizona, Arkansas, California, Illinois, Kentucky, Massachusetts, Minnesota, Nevada, and Ohio.63-64 But the total number of hospitals serving patients is on the rise, with states that expanded Medicaid under the ACA witnessing lower hospital growth than states that did not.65
A nationwide analysis of non-profit and public hospitals’ finances revealed that Medicaid expansion has had no effect on cash flow or operating margins.66 Analysts from Moody’s Investors Services report that there has been “no significant difference” in improved finances among hospitals in expansion states when compared to those in non-expansion states.67 The analysts concluded that other factors, such as macroeconomic conditions and productivity, had a much larger impact on financial performance.68
In fact, some estimates suggest that expanding Medicaid could leave hospitals worse off. While Medicaid expansion advocates tend to focus exclusively on potential reductions to hospitals’ uncompensated care, a more holistic analysis is needed to understand the true impact expansion might have.
In New Hampshire, for example, actuaries estimated that Medicaid expansion would reduce uncompensated care by approximately $9.6 million and increase revenues by another $7.2 million due to higher utilization.69 But those savings and new revenues were more than offset by higher costs and lower reimbursement rates. Actuaries estimated that the costs of higher utilization would reduce hospitals’ income by more than $23 million, while shifting patients from private insurance into Medicaid would reduce reimbursement by nearly $39 million.70 Altogether, New Hampshire providers are estimated to lose more than $47 million as a result of Medicaid expansion.71
Arkansas’ Medicaid expansion model has been an unmitigated disaster. Despite a flurry of initial interest, the model has been resoundingly rejected virtually everywhere it has been proposed.72 Even where the model has taken root, its future is dim. Arkansas policymakers enacted legislation in early 2015 to repeal the expansion entirely at the end of 2016, though the architects of the expansion still hope to revive it.73 The state is now required to send notices to existing enrollees and all new applicants that the program is ending later this year.74
Likewise, the model was such a failure in Iowa that the state scrapped it altogether in 2015, moving the entire expansion population into traditional Medicaid managed care.75 Nebraska should learn from these states’ mistakes, not repeat them.
Nebraska policymakers have taken a cautious approach to the Affordable Care Act, carefully examining the evidence and ultimately rejecting the law’s Medicaid expansion. Their decision has been vindicated by the disasters currently unfolding across the country. Adopting Arkansas’ Medicaid expansion model won’t make any of the Affordable Care Act’s problems go away. It will only make them worse.
FIGURE 12: New Hampshire health system is worse off after Medicaid expansion
Source: New Hampshire Department of Health and Human Services
1. Clerk of the Legislature, “Legislative Bill 472,” Nebraska Legislature (2015), http://nebraskalegislature.gov/FloorDocs/104/PDF/Intro/ LB472.pdf.
3. Milliman, “Nebraska ACA fiscal impact estimate: Updated to reflect Legislative Bill 472,” Nebraska Department of Health and Human Services (2015), http://dhhs.ne.gov/medicaid/Documents/ AffordableCareActMedicaidExpansionFebruary2015.pdf.
8. Author’s calculations based upon projected enrollment, per capita cost, and cost differentials provided by Milliman. These calculations assume the cost differential between qualified health plans and Medicaid for healthy individuals below the poverty line is similar to the differential for healthy individuals above the poverty line.
10. Nic Horton et al., “GAO bombshell: HHS cooked the books to expand ObamaCare in Arkansas,” Forbes (2014), http://www.forbes. com/sites/theapothecary/2014/10/09/gao-bombshell-hhs-cooked-the-books-to-expand-obamacare-in-arkansas.
12. Centers for Medicare and Medicaid Services, “Special terms and conditions: 11-W-00287/6, Arkansas Health Care Independence Program (Private Option),” U.S. Department of Health and Human Services (2015), http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-private-option-ca.pdf.
13. Jonathan Ingram, “Testimony before the Arkansas House and Senate Interim Committees on Public Health, Welfare and Labor,” Foundation for Government Accountability (2014), http:// uncoverobamacare.com/?wpfb_dl=3.
14. Author’s calculations based upon non-smoker premiums of all Silver-tier plans offered on healthcare.gov in each rating area. See, e.g., Health Insurance Marketplace, “2016 FFM QHP landscape data,” U.S. Department of Health and Human Services (2015), https://data.healthcare.gov/download/k2hw-8vcp/application/zip.
15. Health Insurance Marketplace, “2014 FFM QHP landscape data,” U.S. Department of Health and Human Services (2015), https:// data.healthcare.gov/download/ga2z-ezhp/application/zip.
16. Health Insurance Marketplace, “2015 FFM QHP landscape data,” U.S. Department of Health and Human Services (2015), https:// data.healthcare.gov/download/s8rp-rr6e/application/zip.
17. Health Insurance Marketplace, “2016 FFM QHP landscape data,” U.S. Department of Health and Human Services (2015), https:// data.healthcare.gov/download/k2hw-8vcp/application/zip.
18. Stephen T. Parente and Michael Ramlet, “National and state impact analyses of the ACA on insurance prices and enrollment beyond 2014,” University of Minnesota (2014), http://www. washingtonpost.com/blogs/wonkblog/files/2014/05/ParenteAnalysis. pdf.
19. Nebraska Department of Insurance, “Sampling of rates for the federally facilitated marketplace for plan year 2015,” Nebraska Department of Insurance (2014), http://www.doi.nebraska.gov/aca/ consumer/2015RateScenarios.pdf.
20. Nebraska Department of Insurance, “Sampling of final approved changes to individual plan rates for the federally facilitated marketplace for plan year 2016,” Nebraska Department of Insurance (2015), http://www.doi.nebraska.gov/legal/2016_Rate_ Comparison_Scenario.pdf.
22. Jonathan Ingram and Josh Archambault, “Iowa scraps waiver for ObamaCare Medicaid expansion,” Forbes (2015), http://www. forbes.com/sites/theapothecary/2015/09/14/iowa-scraps-waiver-for-obamacare-medicaid-expansion.
28. This projection included both waiver enrollees and medically frail enrollees. See, e.g., Andy Allison, “Estimated Medicaid-related impact of the ACA with expansion: Updated November 13, 2012,” Arkansas Department of Human Services (2012), http://humanservices. arkansas.gov/director/Documents/Updated%20cost%20 estimates%20for%20Medicaid%20expansion%20Nov%202012.pdf.
29. Authors’ calculations based upon monthly per capita costs of “low risk” expansion adults, as “high risk” adults are deemed medically frail and are excluded from the waiver. See, e.g., Optumas, “March 27 estimates,” Arkansas Department of Human Services (2013), http://humanservices.arkansas.gov/director/Documents/March%20 27%20Estimates.pdf.
30. Authors’ calculations based upon projected and actual monthly per capita costs, multiplied by actual enrollment. All cost and enrollment data was provided by the Arkansas Department of Human Services.
32. Jonathan Ingram et al., “ObamaCare’s Medicaid enrollment explosion: A looming fiscal nightmare for states,” Forbes (2015), http://www.forbes.com/sites/theapothecary/2015/07/30/ obamacares-medicaid-enrollment-explosion-a-looming-fiscal-nightmare-for-states.
34. Amy Webb, “Media release: Nearly 70 percent of Arkansans eligible for Private Option signed up in first six months,” Arkansas Department of Human Services (2014), http:// humanservices.arkansas.gov/pressroom/pressroomdocs/ dmsprivateoptionnrapril2014.pdf.
35. Centers for Medicare and Medicaid Services, “Total Medicaid enrollees – VIII Group break out report,” U.S. Department of Health and Human Services (2015), http://www.medicaid.gov/ medicaid-chip-program-information/program-information/ downloads/cms-64-enrollment-report-apr-june-2015.pdf.
36. Authors’ calculations based upon state population and total Medicaid enrollment as of June 2015.
37. Milliman, “Nebraska ACA fiscal impact estimate: Updated to reflect Legislative Bill 472,” Nebraska Department of Health and Human Services (2015), http://dhhs.ne.gov/medicaid/Documents/ AffordableCareActMedicaidExpansionFebruary2015.pdf.
39. Milliman, “Patient Protection and Affordable Care Act: Medicaid fiscal analysis update,” Nebraska Department of Health and Human Services (2013), http://dhhs.ne.gov/medicaid/Documents/ AffordableCareActFiscalAnalysis2013.pdf.11
40. Milliman, “Nebraska ACA fiscal impact estimate: Updated to reflect Legislative Bill 887,” Nebraska Department of Health and Human Services (2014), http://dhhs.ne.gov/medicaid/Documents/ AffordableCareActFiscal%20Analysis%20DRAFTJan2014.pdf.
41. Milliman, “Nebraska ACA fiscal impact estimate: Updated to reflect Legislative Bill 472,” Nebraska Department of Health and Human Services (2015), http://dhhs.ne.gov/medicaid/Documents/ AffordableCareActMedicaidExpansionFebruary2015.pdf.
42. Jonathan Ingram et al., “ObamaCare’s Medicaid enrollment explosion: A looming fiscal nightmare for states,” Forbes (2015), http://www.forbes.com/sites/theapothecary/2015/07/30/obamacares-medicaid-enrollment-explosion-a-looming-fiscal-nightmare-for-states.
43. Jonathan Ingram, “Medicaid expansion: We already know how the story ends,” Foundation for Government Accountability (2013), http://uncoverobamacare.com/wp-content/uploads/2013/10/ Medicaid-Expansion-UncoverObamaCare.pdf.
44. Milliman, “Nebraska ACA fiscal impact estimate: Updated to reflect Legislative Bill 472,” Nebraska Department of Health and Human Services (2015), http://dhhs.ne.gov/medicaid/Documents/ AffordableCareActMedicaidExpansionFebruary2015.pdf.
47. U.S. Department of Health and Human Ser vices, “Federal financial participation in state assistance expenditures; Federal matching Shares for Medicaid, the Children’s Health Insurance Program, and aid to needy aged, blind, or disabled persons for October 1, 2015 through September 30, 2016,” Federal Register 79(231): 71,426-8 (2014), https://aspe.hhs.gov/sites/default/files/pdf/106641/fmap16.pdf.
48. 42 U.S.C. § 1396d(y) (2010), https://www.gpo.gov/fdsys/pkg/ USCODE-2010-title42/pdf/USCODE-2010-title42-chap7-subchapXIX-sec1396d.pdf.
49. Jonathan Ingram, “Who is on the ObamaCare chopping block? The immoral funding formula of ObamaCare’s Medicaid expansion puts the neediest patients at risk,” Foundation for Government Accountability (2014), http://uncoverobamacare.com/?wpfb_dl=33.
50. Jonathan Ingram, “Work requirements work well for welfare: But they still cannot turn a terrible policy into a good one,” Foundation for Government Accountability (2015), http://thefga.org/wp-content/uploads/2015/03/UO-WorkWell-PRINT.pdf.
53. Edward Harris and Shannon Mok, “How CBO estimates the effects of the Affordable Care Act on the labor market,” Congressional Budget Office (2015), http://www.cbo.gov/sites/default/files/114th-congress-2015-2016/workingpaper/51065-ACA_Labor_Market_ Effects_WP.pdf.
54. Authors’ calculations based upon total non-farm employment in the District of Columbia and the 24 states that had expanded Medicaid by January 1, 2014, compared to the 21 states that had not expanded Medicaid as of December 31, 2015. Data for non-farm employment was collected from December 2013 through November 2015.
55. Michigan, New Hampshire, Pennsylvania, Indiana, and Alaska were excluded from the expansion state grouping because each state expanded eligibility after Januar y 2014. Including one or more of these states in the expansion state grouping would have reduced average employment growth.
56. Montana was included in the non-expansion state grouping because its Medicaid expansion did not begin until January 1, 2016. Excluding it from the non-expansion state grouping would have increased average employment growth.
57. Wisconsin was excluded from both groups because the state expanded Medicaid to all non-disabled childless adults below the poverty line, but did not expand to non-disabled childless adults above the poverty line. Including Wisconsin in either group would have had a marginal impact on average employment growth.
59. Deloitte, “Report on Medicaid expansion in 2014,” Kentucky Cabinet for Health and Family Services (2015), http://governor. ky.gov/healthierky/Documents/medicaid/Kentucky_Medicaid_ Expansion_One-Year_Study_FINAL.pdf.
61. Jason Hart, “Kentucky’s Medicaid expansion promises clash with reality,” Watchdog (2015), http://watchdog.org/250803/kentucky-medicaid-expansion-promises.
62. Chris Otts, “Kentucky Medicaid expansion has not produced jobs Beshear claims,” WDRB (2015), http://www.wdrb.com/ story/30603715/kentucky-medicaid-expansion-has-not-produced-jobs-beshear-claims.
63. Cecil G. Sheps Center for Health Services Research, “Rural hospital closures: 65 closures from January 2010 – present,” University of North Carolina (2016), http://www.shepscenter.unc.edu/ download/11619.
64. Caleb Taylor, “Crittenden Regional Hospital not ‘saved’ by the Private Option,” The Arkansas Project (2014), http://www. thearkansasproject.com/crittenden-regional-hospital-not-saved-by-the-private-option.
65. Victoria E. Perez and Ari B. Friedman, “Medicaid expansion and hospital closure,” American Economic Association (2016), https://www. aeaweb.org/aea/2016conference/program/retrieve.php?pdfid=1425.
66. Daniel Steingart et al., “Medicaid expansion linked to lower bad debt amid improving hospital financials,” Moody’s Investors Services (2015), http://www.moodys.com/viewresearchdoc. aspx?docid=PBM_1004691.
69. Authors’ calculations based upon the incremental impact of Medicaid expansion against the baseline of no expansion. See, e.g., Lewin Group, “An evaluation of the impact of Medicaid expansion in New Hampshire: Phase II report,” New Hampshire Department of Health and Human Services (2013), http://www.dhhs.nh.gov/ ombp/documents/nhmedicaidexp-phase-IIrpt.pdf.
72. Lawmakers have rejected similar proposals in Florida, Georgia, North Carolina, Tennessee, Virginia, Utah, and Wyoming.
73. Nic Horton et al., “Arkansas’ Private Option architect hopes to revive the state’s failed ObamaCare Medicaid experiment,” Forbes (2015), http://www.forbes.com/sites/theapothecary/2015/03/17/ arkansas-private-option-architect-hopes-to-revive-the-states-failed-obamacare-medicaid-experiment.
74. Arkansas Bureau of Legislative Research, “Act 831,” Arkansas General Assembly (2015), http://www.arkleg.state.ar.us/ assembly/2015/2015R/Acts/Act831.pdf.
75. Jonathan Ingram and Josh Archambault, “Iowa scraps waiver for ObamaCare Medicaid expansion,” Forbes (2015), http://www. forbes.com/sites/theapothecary/2015/09/14/iowa-scraps-waiver-for-obamacare-medicaid-expansion.