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State Issues

Accomplishments And Challenges In Medicaid Mental Health

PROLOGUE: Medicaid has been a lifeline for people suffering from mental illness, providing access to a range of services to those who are disabled by mental illness or who have limited incomes. Notably, Medicaid pays for prescription medications, an essential component of the treatment package for people with mental health needs. However, this care is quite expensive. Both the price and volume of antipsychotic drugs and antidepressants have increased dramatically, seriously straining states’ resources. In times of state fiscal crisis, it is Medicaid, often the second-largest state budget item after education, that is likely to take the hit. Optional service areas, including case management, community-based services, and unrestricted prescription coverage—areas that were expanded in flusher times—are now targets for retrenchment. Diane Rowland and her colleagues at the Kaiser Commission on Medicaid and the Uninsured detail the competing pressures states face to provide coverage and appropriate care within an environment of reduced resources. Cost containment strategies could well jeopardize the care of a vulnerable segment of the population, threatening to undermine the progress achieved in part through effective but costly drug therapies.

A well-known health policy authority, Rowland is executive vice-president of the Henry J. Kaiser Family Foundation, executive director of the Kaiser Commission on Medicaid and the Uninsured, and adjunct associate professor in the Department of Health Policy and Management at the Johns Hopkins University. She has written about the health care needs of the poor and disadvantaged for many years and has advocated for solutions. Rachel Garfield brings her background in Medicaid eligibility, managed care, and health insurance for low-income children to her position as special assistant to the executive director of the Kaiser Commission; she holds a master’s degree in health policy from the Johns Hopkins Bloomberg School of Public Health. Risa Elias is a senior policy analyst with the Kaiser Commission, focusing on Medicaid, long-term care, and health insurance for people with disabilities. She holds a master’s degree in public policy and a certificate of health services research from Georgetown University.

Abstract

 
Although Medicaid was not designed as a mental health program, it is now a major source of financing for mental health services and care, especially for the chronically mentally ill. This paper examines the role Medicaid plays today for the low-income population with mental health needs and then reviews some of the current pressures and challenges in the program that could reshape this role.

Mental Health Services Within The Medicaid Framework

Top Mental Health Services Within... Challenges In Medicaid’s... Challenges Of Financing Medicaid... Looking Ahead Editor's Notes NOTES

 
Enacted in 1965 as Title XIX of the Social Security Act, Medicaid was intended to make federal matching funds available to states to cover the medical costs of low-income women and children and people over age sixty-five or with disabilities who were receiving welfare assistance. Over time Medicaid has evolved from these welfare roots to become a major source of health and long-term care coverage for low-income Americans.² As Medicaid’s role has expanded, the broad scope of coverage and the flexibility in its benefit design have provided states with an important financing vehicle for mental health services.

As state-only financing for mental health services was increasingly shifted to joint federal-state financing of both institutional and community-based care, Medicaid’s role in mental health grew.³ By 1997 Medicaid was a major payer in the mental health system, accounting for 36 percent of the $48 billion in public mental health funds spent in 1997.⁴ Mental health spending, exclusive of prescription drug costs, now accounts for 10 percent of total Medicaid spending.⁵

How do people get covered under Medicaid? To qualify for Medicaid, people must meet income and asset requirements and also must fall into one of the categories of covered populations, such as poor children or parents, people with disabilities receiving cash assistance, or poor Medicare beneficiaries. Although there is no eligibility group explicitly tied to mental illness, the structure of the program allows states to provide coverage for people with mental disabilities as well as coverage of basic mental health services for other beneficiaries.

While only 4 percent of program beneficiaries qualify for Medicaid because of a mental disorder that qualifies them as disabled, a much larger share of enrollees (13 percent) rely on Medicaid for mental health benefits.⁶ About one-third (36 percent) of those receiving mental health benefits from Medicaid qualify for the program as the result of a disability. Another third (32 percent) are children who qualify on the basis of their age and income rather than their mental health needs. Pregnant women and adult caretakers of children eligible for Medicaid (29 percent) and other low-income people (3 percent) account for the remaining third of Medicaid users of mental health services.⁷

For those who qualify for coverage, Medicaid provides broad insurance coverage to meet both mental health and physical health needs. Without Medicaid, these people would likely be uninsured, relying on state-operated mental health systems to meet their mental health needs as they arose. With Medicaid, they have comprehensive insurance and receive treatment for a broad range of health needs. Indeed, one study found that mentally ill Medicaid beneficiaries rely heavily on the breadth of their insurance coverage: Their health expenses for non–mental health services were twice as high as those for mental health services.⁸ Evidence also shows that the replacement of insurance coverage for direct services for mental health improves access to care for covered people. For example, one study found that Medicaid beneficiaries are about 70 percent more likely than poor or near-poor people without Medicaid coverage are to have received mental health services.⁹

What does Medicaid provide? States participating in Medicaid provide beneficiaries with a comprehensive benefit package of preventive, acute, and long-term care services, with some services required by federal law ("mandatory services") and others offered at state option ("optional services"). Similar to eligibility, mental health benefits are not explicitly included in the required set of Medicaid benefits but are covered under several broad categories of benefits, many of which are optional services (such as prescription drugs, case management services, and home and community-based services).¹⁰ The broad definitions of the service categories outlined in federal Medicaid law enable states—with a few notable exceptions—to provide a broad range of mental health benefits through their programs.

Mental health benefits available under Medicaid are generally more comprehensive than those offered by other payers. Even with private insurance or Medicare coverage, mentally ill low-income people could face sizable barriers to care. The federal Medicare program imposes cost sharing and does not cover outpatient prescription drugs, a benefit that has become vital to the treatment of many mental illnesses.

Similarly, despite federal mental health parity legislation, as well as parity laws in thirty-three states, gaps persist in private insurance coverage of mental health services.¹¹ One survey found that only about two-thirds of plans covered intensive nonresidential care, and slightly more than a third covered nonhospital residential care.¹² Workers with employer-sponsored insurance often face limits on mental health benefits, with almost a third having a limit of twenty or fewer outpatient visits and half having a limit of thirty days or fewer for inpatient care.¹³

Medicaid pays for mental health services without many of the restrictions of other plans and often is the only payer to cover the health services that are critical to people with mental health needs. For example, the program covers long-term care, a service that is rarely available in private plans but that can quickly deplete the income and savings of even moderate-income people. Medicaid also provides an array of services outside the traditional medical/psychiatric model, such as transportation assistance, supportive services in the home, respite care, and case management. Finally, unlike many private insurance plans, Medicaid does not have preexisting condition exclusions, nor does it impose a waiting period for coverage; rather, anyone who meets the income and disability eligibility requirements can receive coverage.

How is Medicaid paid for? Medicaid is an open-ended entitlement program, jointly financed by the federal and state governments. Financing mental health services through Medicaid appeals to states because the cost is shared between the state and federal governments, with the federal government paying 50–77 percent of expenditures (depending on the state). The federal government matches whatever states spend on eligible beneficiaries without a cap on total spending. This structure has enabled states to expand services with fewer state dollars and obtain federal financial assistance for services, such as institutional care, that were previously provided with only state funds.¹⁴

In helping states expand services, Medicaid financing has been an important resource to support changing patterns of mental health care. As states deinstitutionalized psychiatric patients, Medicaid helped finance community-based care and prescription drugs to facilitate this process.¹⁵ Medicaid coverage has also enabled many people with mental health needs to get access to new or emerging treatments, ranging from new pharmaceuticals to comprehensive treatment programs such as assertive community treatment (ACT).¹⁶

In many areas of mental health, Medicaid has been tapped repeatedly as an open source of funds to replace state-only dollars with federal matching dollars, most notably for care formerly provided in state mental facilities with state dollars. However, in one area—nursing and hospital services in an institution for mental disease (IMD)—states have not been able to shift the cost of care to their Medicaid programs. Under federal Medicaid rules, states can provide this benefit for people age sixty-five or older and can provide inpatient psychiatric hospital care to people under age twenty-one, but they may not use Medicaid to finance care for other people in these facilities. This exemption was originally intended to prevent the wholesale shifting of state responsibility and payment of state institutions for the mentally ill to Medicaid, but budget constraints have left the exclusion in place.¹⁷ The outcome, however, has created incentives for states to treat patients in other types of facilities and to look to recover federal financing in other areas.

Challenges In Medicaid’s Evolving Role In Mental Health

Top Mental Health Services Within... Challenges In Medicaid’s... Challenges Of Financing Medicaid... Looking Ahead Editor's Notes NOTES

 
As Medicaid’s role in mental health has evolved, the program has been under increased pressure to broaden the availability of care in the community as an alternative to institutional care. In addition, the transition to managed care arrangements for most Medicaid enrollees has raised issues regarding the provision of mental health services in managed care arrangements, and advocates of people with disabilities have also brought increased pressure to modify eligibility rules and facilitate coverage for people with disabilities who work.

Pressure to shift to community-based care. Although states have been making progress in providing community-based alternatives to institutional care, the demand still greatly exceeds the availability of these services. Over the past twenty years a number of incremental steps have been taken to increase home and community-based care services, but transferring long-term care services to the community remains a priority.

1915(c) waivers. In 1981 Congress gave states the ability to provide home and community-based services to people who would otherwise qualify for institutional care. Using 1915(c) waivers, states can provide a broad range of services (such as case management, personal care services, and respite care) that are not usually covered by Medicaid, to prevent a person from being institutionalized.¹⁸ States also have the authority to target certain populations, and in 2002 they used such waivers to provide home and community-based care for 800,000 people with mental retardation and developmental disabilities, people with physical disabilities, and elderly people.¹⁹ However, for people with mental illness, waivers have provided limited assistance; only three states (Colorado, Kentucky, and Vermont) have waivers that specifically target people with mental health needs.²⁰ Enrollment in these three states’ waiver programs represents less than 1 percent of total enrollment in 1915(c) waivers.²¹

The Olmstead decision The 1999 Supreme Court ruling in Olmstead v. LC requires states to provide services to people with disabilities in community settings, rather than institutions. States are to develop "comprehensive working plans for placing qualified persons with disabilities in the most integrated setting appropriate" and to maintain a "waiting list that moves at a reasonable pace."²²Olmstead holds the promise of further expanding the availability of community-based alternatives for people with long-term care needs—including the mentally ill—but states have been slow to comply. Four years after the ruling, only forty-two states and the District of Columbia have even developed implementation plans.²³

New Freedom Initiative In another step to increase access to community-based care, the Bush administration has promoted the New Freedom Initiative, a nationwide effort to remove barriers to community living for people with disabilities. The initiative calls for the implementation of the Olmstead decision, integration of people with disabilities into the workforce through the Ticket to Work and Work Incentives Act, and increased opportunities for consumer direction of care.²⁴

One part of the New Freedom Initiative that aims to promote community-based care is Independence Plus waivers. These waivers are an expansion of the Cash and Counseling waivers that were established by the U.S. Department of Health and Human Services (HHS) in 1996, with financial support from the Robert Wood Johnson Foundation. States can use either Medicaid Section 1915(c) or Section 1115 waivers to give the elderly and people with disabilities (including those with mental illness) greater involvement, control, and choice in identifying, accessing, and managing the home and community-based services they need.

Although these waivers offer greater independence, their success hinges on whether or not the state provides adequate personal budgets to cover beneficiaries’ medical needs. In addition, although these waivers give beneficiaries more control over their care, they do not necessarily increase the overall availability of community-based services, raising the potential for access problems. Thus far Florida, South Carolina, and New Hampshire have approved waivers.²⁵ These waivers do not include people with mental illness, and it is still too early to know whether states will use these waivers to do so.

The administration continues to build on the New Freedom Initiative. Included in the fiscal year 2004 budget proposal are several demonstrations that promote home and community-based care alternatives under Medicaid, two of which could have a direct impact on people with mental illness. The first demonstration would provide community-based care alternatives to psychiatric residential treatment for children. Under the second demonstration, Money Follows the Individual, the federal government would assume the cost of providing home and community-based services for a twelve-month period for people who are moved out of institutions into the community. Although there is still much progress to be made in the shift to community-based care, these proposals give Medicaid long-term care programs the tools they need to continue to evolve to meet the demand for home and community-based services.

Managed care and mental health services. In addition to the pressure to expand community-based services, Medicaid itself was transforming the financing and delivery of acute care services from fee-for-service to managed care in the 1980s and 1990s. As states faced increasing cost pressure in the 1990s, they turned to managed care as a way to increase access to providers and coordinate care while making health costs for beneficiaries more predictable. By 1999 more than half of all Medicaid beneficiaries were enrolled in managed care, a sevenfold increase from 1991.²⁶ Initially, most managed care enrollees were from low-income families, but as managed care has evolved, many states have also moved people with disabilities into managed care arrangements.

Overall, states’ experiences with Medicaid managed care have been mixed, with some successfully controlling costs or improving access to care, or both, and others having difficulty with risk adjustment and plan participation. Similarly, beneficiaries’ experiences have been varied, with studies generally showing improvements in access to regular providers but problems in enrollees’ satisfaction and access to needed services.

The shift in delivery systems has important implications for beneficiaries with mental health needs. Mental health services may be included in contracts with managed care organizations or may be excluded from managed care altogether and provided on a fee-for-service basis.²⁷ Each arrangement presents its own advantages and challenges, with some better able to coordinate mental and physical care, others better able to provide specialized services for people with mental health needs, and others able to insulate enrollees from financial disincentives and potential plan withdrawals.

Assessments of managed care’s role for people with mental health needs are ongoing and show mixed results. As states move to extend managed care to more enrollees with disabilities, a better understanding of what models work best for people with mental health needs is needed.

Addressing eligibility limits. The major eligibility pathway for Medicaid coverage for the mentally ill population is to qualify as disabled by meeting the eligibility criteria for the Supplementary Security Income (SSI) cash assistance program. These criteria include meeting the income and resource limits for eligibility as well as meeting the definition of disability, which includes a requirement that the person not be able to engage in "substantial gainful activity." These requirements both limit the availability of coverage for those with income or assets above the SSI standards (typically 74 percent of the federal poverty level for income and $2,000 in assets) and restrict those covered from being able to work. As a result, many people with mental health needs are unable to gain Medicaid coverage.

Most of the recent activity around Medicaid eligibility for people with disabilities, including those with mental health needs, has focused on expanding work opportunities without compromising their ability to retain Medicaid coverage. Through the Balanced Budget Act (BBA) of 1997 and the Ticket to Work and Work Incentives Act, Congress created Medicaid "buy-in" options for people who meet the SSI program definition of disability and would be able to work if they retained their health coverage. The BBA allows states to provide Medicaid to people with disabilities with incomes up to 250 percent of poverty ($3,179 per month for a family of three in 2003). States using the Ticket to Work legislation can set higher income and resource levels and extend Medicaid coverage to working people with disabilities whose health conditions improve, a provision particularly important for people with mental health needs who are able to function with medication.²⁸

Although these buy-in programs have the potential of broadening the reach of Medicaid, only 17,000 people are covered in the fifteen states that have picked up the option.²⁹ Additional states have shown interest in implementing buy-in programs, but expanded coverage for this group appears unlikely under the current fiscal constraints.

Challenges Of Financing Medicaid Services

Top Mental Health Services Within... Challenges In Medicaid’s... Challenges Of Financing Medicaid... Looking Ahead Editor's Notes NOTES

 
The pressure to improve coverage and access under Medicaid inevitably runs up against the tough realities of financing the program. Medicaid is jointly financed by the federal and state governments, with the federal government providing open-ended matching funds to states for the cost of care for eligible people. The federal Medicaid statute sets requirements for the use of Medicaid funds, but states continually seek additional flexibility in the use of federal matching funds. When federal funds restrict states from providing certain coverage or services and when states engage in creative financing arrangements to use Medicaid funds for other purposes, the relationship becomes strained.

This financing tension within Medicaid has been particularly salient in the area of mental health. As discussed earlier, Medicaid has been tapped repeatedly as an open source of funds to replace state-only dollars with federal matching dollars, most notably for care formerly provided in state mental facilities with state dollars. Known as "Medicaid maximization," this financing strategy has been a major force behind Medicaid’s expanding role in mental health. However, states still feel that federal rules (such as the IMD exclusion) restrict them from financing certain services for beneficiaries and refinancing additional mental health services.

In addition to states’ efforts to refinance state expenditures with federal matching funds, many states have also turned to federal waivers to broaden the populations and services they can cover and receive matching funds. Under the Health Insurance Flexibility and Accountability (HIFA) demonstrations, the HHS secretary has approved Medicaid waivers that provide much more limited benefits than under traditional Medicaid programs. For example, under the Utah waiver, mental health services are not included in the benefit package being offered to newly insured adults; prescriptions are limited to four per month, with no exceptions, and are subject to substantial cost sharing; while parents already covered by Medicaid face reduced coverage and higher cost sharing for both inpatient and outpatient mental health services.³⁰ Efforts that trim the benefit package and impose cost sharing, especially for prescriptions, could result in benefits that are inadequate for those who turn to Medicaid for assistance with mental health needs.

Much of the impetus behind states’ efforts to alter benefits stems from the current fiscal crisis facing most states and the resulting need to control and reduce spending. Preliminary estimates for 2002 show that state tax revenue collections have dropped by nearly 6 percent, the first annual decline since World War II.³¹ As a result, state budget shortfalls are estimated to rise from $37 billion in FY 2002 to almost $70 billion in FY 2004.³² This puts Medicaid spending at the center of state budget battles, as Medicaid accounts on average for 15 percent of state budgets—the largest component of state spending after education.³³

The state-level budget crisis puts vulnerable populations, including those with mental health needs, at risk. For FY 2003 forty-five states have undertaken cost containment strategies for prescription drugs, thirty-seven are freezing or reducing payment rates to providers and managed care plans, and twenty-five are proposing to reduce benefits and restrict eligibility for coverage.³⁴ Many are also looking to increase copayments for some covered services, especially prescription drugs. Most predict even deeper cuts in FY 2004 in the absence of fiscal relief.

Many programwide steps taken by states will disproportionately affect people with mental illness. For example, many of the services these populations rely on (most notably, prescription drug coverage, case management, and home and community-based services) are among the benefits offered at state option and therefore could be cut back or eliminated in tight fiscal times. Oregon’s recent decision to stop covering many drugs to address budget gaps highlights the problem: Both state officials and advocates note that the move most seriously hurts the mentally ill, many of whom cannot function without their medications.³⁵ In addition, reduced payments to providers could further compromise access to care or could undermine the fiscal stability of providers that largely serve this population.

States facing budget shortfalls are likely to reexamine their coverage for people with mental illness, who are among the costliest populations to serve. Such beneficiaries constitute only 11 percent of Medicaid beneficiaries, but they account for a third of high-cost beneficiaries.³⁶ High per capita cost is due to the fact that people with mental illness often have multiple, complex health needs. It is also due to the fact that mental illness can be very costly to treat. A study of Oklahoma’s Medicaid population revealed that beneficiaries with a single diagnosis of psychosis or depression had the highest average yearly costs of all physical and mental medical conditions studied.³⁷

One reason for the high cost of care for this population is prescription drug use, which is one of the fastest-growing areas of Medicaid spending. Most Medicaid beneficiaries with schizophrenia or affective disorders use psychotropic drugs covered by Medicaid, with the majority using more than one prescription for their mental health needs.³⁸ Although the advent of new pharmaceutical technologies is helping these people lead more productive lives, such advances come at a price. From 1992 to 1998 Medicaid payments for antipsychotic drugs grew by nearly 300 percent, and spending on antidepressants grew more than 240 percent.³⁹ Only payments for antiretrovirals for treatment of HIV outpaced this growth.

Looking Ahead

Top Mental Health Services Within... Challenges In Medicaid’s... Challenges Of Financing Medicaid... Looking Ahead Editor's Notes NOTES

 
While the fiscal situation at the state level and the implications of the proposed cuts for beneficiaries and providers are clear, the solution to the problem is not. States are pressed to preserve the benefits that are critical to people with mental health needs while also addressing politically popular issues such as coverage for low-income children and prescription drug assistance for seniors.

As the states look to the federal government for fiscal relief, the call for financial assistance has sparked discussions of a major restructuring of Medicaid. A proposal advanced by the Bush administration as part of the FY 2004 budget would give states the choice of operating their Medicaid programs with almost complete flexibility with regard to coverage of beneficiaries and benefits offered at state option, in return for a cap on federal funding. The open-ended matching funds would be replaced by a fixed allocation of federal funds based on prior spending trended forward. In return for this flexibility over coverage and benefits, states would forgo the current flexibility over financing.

If enacted, this proposal would greatly alter the coverage and financial incentives embodied in Medicaid’s current role in financing mental health services. States’ efforts to expand coverage for people with mental health needs would be placed in direct competition with other health priorities within capped federal funding. Efforts to shift mental health services to Medicaid to obtain federal matching funds would end. Moreover, since many of the services used by people with mental health needs are offered at state option and are costly, they are likely to be among the early candidates for reductions.

As this proposal and other options to reform Medicaid and address states’ fiscal pressures are debated, the future shape of Medicaid coverage for low-income Americans and its role in mental health services are at the center of the fray. The outcome of the emerging debate will determine Medicaid’s future role as the safety net for health and mental health coverage for poor and vulnerable populations.

Editor's Notes

Top Mental Health Services Within... Challenges In Medicaid’s... Challenges Of Financing Medicaid... Looking Ahead Editor's Notes NOTES

 
The authors are grateful to the reviewers for their thoughtful comments and to Anne Williams for her administrative assistance.

NOTES

Top Mental Health Services Within... Challenges In Medicaid’s... Challenges Of Financing Medicaid... Looking Ahead Editor's Notes NOTES

 

1. Kaiser Commission on Medicaid and the Uninsured estimates based on March 2002 baseline estimates from the Congressional Budget Office.
2. D.Rowland and J.R. Tallon Jr., "Medicaid: Lessons from a Decade," Health Affairs (Jan/Feb 2003): 138–144.
3. R.G.Frank, H.H. Goldman, and M. Hogan, "Medicaid and Mental Health: Be Careful What You Ask For," Health Affairs(Jan/Feb 2003): 101–113.
4. R.Coffey et al., National Estimates of Expenditures for Mental Health and Substance Abuse Treatment, 1997 (Rockville, Md.: Substance Abuse and Mental Health Services Administration, July 2000).
5. J.Buck and K. Miller, "Nonpsychiatric Inpatient Use of Medicaid Mental Health Service Users," Psychiatric Services 54, no. 3 (2003): 300.[Free Full Text]
6. Kaiser Commission on Medicaid and the Uninsured, unpublished analysis based on Urban Institute analysis of HCFA-2082 and HCFA-64 data. One in ten Medicaid beneficiaries use mental health services. See J. Buck and K. Miller, Mental Health and Substance Abuse Services in Medicaid, 1995 (Rockville, Md.: SAMHSA, 2002). An additional 2–3 percent of Medicaid beneficiaries use psychoactive drugs covered by Medicaid but do not use other Medicaid mental health services, according to data from the SAMHSA Office of Organization and Financing, 2000.
7. J.Buck et al., "Mental Health and Substance Abuse Services in Ten State Medicaid Programs," Administration and Policy in Mental Health 28, no. 3 (2001): 181–192.[CrossRef][ISI][Medline]
8. Ibid.
9. C.A.Taube and A. Rupp, "The Effect of Medicaid Access to Ambulatory Mental Health Care for the Poor and Near-Poor under 65," Medical Care 24, no. 8 (1986): 677.[ISI][Medline]
10. For more detail, see A.Schneider and R. Garfield, "Medicaid Benefits," in A. Schneider et al., The Medicaid Resource Book (Washington: Kaiser Commission on Medicaid and the Uninsured,July 2002),49–80.
11. Federal mental health parity law aims to assure equal annual and lifetime dollar limits on mental health care and care for other illnesses, while state laws typically require insurers to provide benefits for mental illnesses that are equal to the benefits provided for physical illnesses. See National Mental Health Association, "It Is Time to Pass Comprehensive Health Insurance Parity!" www.nmha.org/state/parity/index.cfm (10 June 2003).
12. J.Buck and B. Umland, "Covering Mental Health and Substance Abuse Services," Health Affairs (July/Aug 1997): 120–126.
13. HenryJ. Kaiser Family Foundation and Health Research and Educational Trust, Employer Health Benefits, 2002 Annual Survey (Washington: Kaiser Family Foundation, 2002), 130.
14. Frank et al., "Medicaid and Mental Health," 105–107.
15. Ibid.,101–113.
16. Health Care Financing Administration, Letter to State Medicaid Directors, 7 June 1999, www.cms.hhs.gov/states/letters/smd60799.asp (18 April 2003).
17. Congressional Research Service, Medicaid Source Book: Background Data and Analysis (A 1993 Update) (Washington: U.S. Government Printing Office, January 1993),917–918.
18. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Understanding Medicaid Home and Community Services: A Primer (Washington: DHHS, October 2000).
19. Estimates based on unpublished Medicaid home and community-based services data collected by Charlotte Harrington for the Kaiser Commission on Medicaid and the Uninsured, 2003.
20. Ibid.
21. Ibid.
22. HCFA, Letter to State Medicaid Directors.
23. W.Fox-Grage et al., The States’ Response to the Olmstead Decision: How Are States Complying? (Washington: National Conference of State Legislatures, 2003).
24. Centers for Medicare and Medicaid Services, "Fulfilling America’s Promise to Americans with Disabilities: New Freedom Initiative," 2 June 2003, www.cms.hhs.gov/newfreedom/default.asp (10 June 2003).
25. J.Crowley, Independence Plus Waivers (Washington: Kaiser Commission on Medicaid and the Uninsured, 2003).
26. CMS, "Medicaid Managed Care Enrollment Statistics," 26 March 2003, www.cms.hhs.gov/medicaid/managedcare/enrolstats.asp (18 April 2003).
27. K.Hanson and H. Huskamp, "Behavioral Health Services under Medicaid Managed Care: The Uncertain Implications of State Variation," Psychiatric Services 52, no. 4 (2001): 447–450.[Free Full Text]
28. Schneider and Garfield, "Medicaid Eligibility," 4–48.
29. E.Fishman and B. Cooper, Medicaid Buy-in Options: Helping Persons with Severe Disabilities and Chronic Conditions Work (New York: Mount Sinai School of Medicine, 2002).
30. Kaiser Commission on Medicaid and the Uninsured, "Utah Section 1115 Waiver Fact Sheet" (Washington: Kaiser Commission, 2003).
31. N.W.Jenny, Continued Weakness in State Tax Revenue (New York: Rockefeller Institute of Government, December 2002).
32. NCSL, State Budget and Tax Actions, Preliminary Report (Washington: NCSL, 2002).
33. National Association of State Budget Officers, 2001 State Expenditure Report (Washington: NASBO, Summer 2002).
34. V.Smith et al., Medicaid Spending Growth: A Fifty-State Update for Fiscal Year2003 (Washington: Kaiser Commission,January 2003).
35. T.Egan, "A Prescription Plan Hailed as a Model Is a Budget Casualty," New York Times,5 March 2003.
36. J.Buck et al., "Use of Mental Health and Substance Abuse Services among High-Cost Medicaid Enrollees," Administration and Policy in Mental Health (forthcoming).
37. R.Garis and K. Farmer, "Examining Costs of Chronic Conditions in a Medicaid Population," Managed Care (August 2000):43–50.
38. K.Hennessey et al., "Use of Psychotropic Drugs by Mentally Ill Medicaid Beneficiaries," Psychiatric Services 53, no. 9 (2002): 1070.[Free Full Text]
39. Preliminary data from study by the PRIME Institute, University of Minnesota, based on data from CMS Medicaid Drug Rebate Program public use files.

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