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Trend #9: State Abuse of Medicaid Matching Funds

When states set aside money to be spent on Medicaid, the federal-state program providing health care to low-income Americans, they receive matching funds from the federal government. These matching funds are made available according to a formula known as the Federal Medical Assistance Percentages (FMAP), based on the state’s level of poverty and unemployment.[1]

For example, in Fiscal Year 2012, Mississippi has the highest FMAP (74.18 percent), meaning that for every $1.00 Mississippi spends on Medicaid, the federal government kicks in $2.87. Fourteen states tie for the lowest FMAP (50 percent), which means that for every $1.00 they spend on Medicaid, the federal government kicks in another $1.00. (See Table for complete list.)

Table: Federal Medicaid Matching Fund Rates and States with Health Provider Taxes

State
Federal Medicaid Matching Fund Rate, FY 2012
Federal Contribution for Every Spent State Medicaid Dollar
Rank
Increased Health Provider Tax in 2009 or 2010
Alabama 68.62% $2.19 9 X
Alaska 50.00% $1.00 37
Arizona 67.30% $2.06 10
Arkansas 70.71% $2.41 5
California 50.00% $1.00 37
Colorado 50.00% $1.00 37 X
Connecticut 50.00% $1.00 37
Delaware 54.17% $1.18 34
Florida 56.04% $1.27 31 X
Georgia 66.16% $1.96 13 X
Hawaii 50.48% $1.02 36
Idaho 70.23% $2.36 7 X
Illinois 50.00% $1.00 37
Indiana 66.96% $2.03 11 X
Iowa 60.71% $1.55 23 X
Kansas 56.91% $1.32 28 X
Kentucky 71.18% $2.47 3
Louisiana 61.09% $1.57 22
Maine 63.27% $1.72 20 X
Maryland 50.00% $1.00 37
Massachusetts 50.00% $1.00 37
Michigan 66.14% $1.95 14
Minnesota 50.00% $1.00 37
Mississippi 74.18% $2.87 1 X
Missouri 63.45% $1.74 19
Montana 66.11% $1.95 15
Nebraska 56.64% $1.31 29
Nevada 56.20% $1.28 30
New Hampshire 50.00% $1.00 37
New Jersey 50.00% $1.00 37 X
New Mexico 69.36% $2.26 8
New York 50.00% $1.00 37 X
North Carolina 65.28% $1.88 16
North Dakota 55.40% $1.24 32
Ohio 64.15% $1.79 17 X
Oklahoma 63.88% $1.77 18
Oregon 62.91% $1.70 21 X
Pennsylvania 55.07% $1.23 33 X
Rhode Island 52.12% $1.09 35 X
South Carolina 70.24% $2.36 6
South Dakota 59.13% $1.45 25
Tennessee 66.36% $1.97 12 X
Texas 58.22% $1.39 26
Utah 70.99% $2.45 4 X
Vermont 57.58% $1.36 27
Virginia 50.00% $1.00 37
Washington 50.00% $1.00 37 X
West Virginia 72.62% $2.65 2
Wisconsin 60.53% $1.53 24 X
Wyoming 50.00% $1.00 37
District of Columbia 70.00% $2.33 (8)

Because Medicaid’s federal matching is open-ended, states can abuse it to bridge budget gaps. In 2004, the U.S. government’s General Accounting Office (GAO, now the Government Accountability Office) warned that the design of Medicaid matching funds enabled states to funnel Medicaid money into state general coffers. During the recent downturn, many states did exactly that.[2] They do so by taxing health care providers, using the collected revenue to qualify for federal matching funds, and then using the federal dollars to compensate Medicaid providers.

MedicaidThese hospital taxes or doctors’ taxes exist in 46 states and the District of Columbia.[3] During the recent economic downturn, 20 states increased health provider taxes to take advantage of federal matching funds, particularly because the 2009 stimulus bill temporarily made FMAP federal matching fund rates more generous. (In 2009, FMAP matching fund rates ranged from 56.2 percent to 83.6 percent.) States’ use of the matching funds to backfill general state spending led to a sharp jump in federal Medicaid expenditures, from $201 billion in 2008 to $250 billion in 2009.[4] As states receive more federal funds for Medicaid, the federal government must tax or borrow to pay for this spending increase.

As one example of a flurry of new state medical taxes, in 2009, Wisconsin Governor Jim Doyle (D) pushed through a 20 percent increase in the state’s health provider tax. The tax increase led to an increase of federal matching funds received by the state from $635 million to $796 million, with an estimated $292 million of the money being diverted for non-Medicaid uses.[5] Health care providers that benefit from increased Medicaid reimbursements often support these taxes if the returns exceed the tax payments.[6] The actual purpose of these taxes is to obtain additional federal funds.

Those states that were most likely to abuse Medicaid matching funds are those states that have been most irresponsible with managing their state budget. Their use of Medicaid funds to backfill other state programs is at odds with the purpose of the Medicaid program, but the open-ended nature of federal matching encourages this practice. While using health provider taxes and abusing Medicaid matching funds can temporarily patch a state budget, these solutions rely on the continued dysfunction of the Medicaid matching fund system.

Note: This publication is part of our "Top 10 State Tax Trends in Recession and Recovery" series.

[1] See Department of Health & Human Services, 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 FY 2012, 75 Fed. Reg. 217 (Nov. 10, 2010), http://aspe.hhs.gov/health/fmap12.shtml.

[2] See Justin Higginbottom, State Hospital and Medical Provider Taxes: Not What the Doctor Should Order, Tax Foundation Fiscal Fact No. 203 (Dec. 9, 2009), http://www.taxfoundation.org/news/show/25599.html.

[3] National Conference of State Legislatures, Health Care Providers and Industry Taxes/Fees (Feb. 2012), http://www.ncsl.org/issues-research/health/health-provider-and-industry-state-taxes-and-fees.aspx.

[4] U.S. Office of Management & Budget, The President’s Budget for Fiscal Year 2013: Historical Tables (2012), http://www.whitehouse.gov/omb/budget/Historicals.

[5] See Brien Farley, Wisconsin Seeks More Medicaid Money to Heal Sick State Budget, Heartland Budget & Tax News (Nov. 3, 2009), http://news.heartland.org/newspaper-article/2009/11/03/wisconsin-seeks-more-medicaid-money-heal-sick-state-budget.

[6] In one state, a hospital association opposed the hospital assessment, concluding that the state planned to siphon so much money that they would not be fully reimbursed from higher Medicaid payments. See Ohio Hospital Association, New State Hospital Tax: Extra Burden in a Failing Economy (Nov. 2009), http://ohanet.org/SiteObjects/57AEE3CFB2585F16682EF98E1BBE3B48/State%20Budget%20Survey%20Report.pdf.

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