The State of State Health Policy: Governors’ 2016 State of the State Addresses
State of State speeches provide governors with an opportunity to highlight recent policy successes as well as outline key plans and issue areas of focus for the coming year. These speeches are generally strong indicators of governors’ main priorities and sometimes also include specific proposal suggestions and funding recommendations for deliberation by legislatures.
Currently, 31 governors are Republican, 18 are Democrats and one is an Independent. Two states—Kentucky and Louisiana—elected new governors in 2015. So far this year, 40 governors have outlined policy priorities through state of state speeches and/or budget addresses.[1] The chart and descriptions below summarize some of the main health-related themes from these speeches.
See a state-by-state comparison
Six governors mentioned the issue of more broadly addressing population health and building healthy communities.
|
Launching Great State 2019 Plan in honor of state’s upcoming 200th birthday; initiative will focus on addressing longstanding problems from healthcare to prison reform and will involve building opportunities for citizens, and promoting education, healthcare, access to technology, job growth and economic opportunity |
|
|
Highlighted poverty’s negative effects and mentioned state’s Two Generation initiative to address poverty that links with the state’s efforts to be the healthiest in the nation; initiative recognizes that residents’ health has economic and overall quality of life impacts; also importance of reducing children’s screen time and the need to promote healthier behaviors such as involvement in outdoor activities |
|
|
Will be investing in issue of homelessness, which will include addressing the needs of the most vulnerable homeless, such as those with chronic health conditions |
|
|
Need to make more coordinated investments and transform towards focusing more intensely on prevention and public health and paying for outcomes rather than volume and services |
|
|
Noted that safe and healthy communities are the foundation of the state; to maintain the state’s high quality of life investments should continue in priorities that support economic growth |
|
|
Mentioned consumer health concerns regarding access to safe and healthy food and the need for meaningful food labeling |
In addition to mentioning health care costs within the context of Medicaid, eight governors also spoke about state health care costs more broadly; often mentioning costs associated with state employee health benefits.
|
Noted that state has not allocated enough funding to cover future retiree health benefits for state workers |
|
|
Identified sharply rising health care costs as the state’s biggest challenge, particularly costs of state employee health plans; also importance of shifting from fee-for service health care to a system focused on high quality and affordable outcomes, and ensuring that individuals appropriately use care to help reduce overall costs |
|
|
Commented on the rising costs of mandated health care expenditures for state employees |
|
|
Mentioned state employee health care obligations as one of the state’s biggest fixed expenses, but recent changes to how these obligations are funded will save costs in the future |
|
|
Noted state budget crisis and need for new revenue to avoid severe cuts in assistance programs for disabled individuals and other health programs and potentially having to close safety net hospitals |
|
|
Noted that if state does not address $2 billion budget deficit will have to make significant cuts to basic state services, including health programs such as prescription drug assistance for seniors, services for individuals with mental illness and disabilities, and home and community-based services |
|
|
Mentioned the rising cost of health care as the most significant challenge to the state’s budget and the overall economy as well as creates challenges for families and businesses; noted state’s current work to shift from fee-for-service to an all-payer model focused on better health outcomes and targeted provider spending |
|
|
Commented on the need to reform the administration of state employee health insurance to achieve savings |
In total, 17 governors mentioned the issue of Medicaid and/or Medicaid expansion in their speeches. Specifically, 11 governors provided general comments about their states’ Medicaid programs in their remarks, such as commenting on recent program improvements or the growth of overall program costs.
|
Mentioned commitment to implement Medicaid reforms to improve the state’s Medicaid program |
|
|
Noted positive benefits of state’s Medicaid program but that there has been a significant rise in state Medicaid costs; requests legislature consider proposal to restructure taxes on Medicaid managed care organizations |
|
|
Commented that state Medicaid costs have increased from $2.6 billion in FY2013 to $3.1 billion in FY2017 |
|
|
Mentioned plans to move to a Medicaid managed care system to improve care coordination and address significantly rising state Medicaid costs |
|
|
Recent reforms and modernizations to Medicaid program have demonstrated cost savings and also resulted in more client services and increased provider reimbursement rates |
|
|
Access to in-home Medicaid services for individuals with developmental disabilities has significantly improved |
|
|
Noted significant rise in state Medicaid costs |
|
|
Highlighted the success of TennCare as a well-run system with high customer satisfaction ratings |
In total, 17 governors mentioned the issue of Medicaid and/or Medicaid expansion in their speeches. Specifically, 11 governors provided general comments about their states’ Medicaid programs in their remarks, such as commenting on recent program improvements or the growth of overall program costs. Thirteen governors mentioned Medicaid expansion in their speeches. Eight were governors that have not implemented expansion, and five of these governors spoke about the need to expand Medicaid or find another state-specific solution to cover the uninsured (Missouri, South Dakota, Utah, Virginia, and Wyoming). Two governors (Kansas and Nebraska) expressed continued opposition to expansion. Kentucky’s newly elected governor mentioned plans to transform the delivery of publicly assisted health care and to make changes to the state’s traditional Medicaid expansion, although the proposed budget contains funding for expansion in its current form.
|
Noted expansion has resulted in greater health coverage for residents and state has benefited from increased federal revenue from expansion |
|
|
Mentioned expansion has resulted in greater health coverage for residents |
|
|
Highlighted the work of cabinet in exploring Medicaid expansion alternatives; also mentioned recently released plan to provide state-funded primary care |
|
|
Mentioned state’s unique expansion program has resulted in increased access to health care and is based on personal responsibility |
|
|
Noted continued opposition to implementing expansion |
|
|
Mentioned plans to transform delivery of publicly assisted health care and to make changes to the state’s current Medicaid expansion; proposed budget contains funding for current expansion |
|
|
Suggested state should act to cover the uninsured through expansion; can develop a state-tailored solution that rewards work and incorporates personal responsibility |
|
|
Noted continued opposition to implementing expansion |
|
|
Urged legislators to support continuation of the Health Protection Program, the state’s Medicaid expansion program, which has increased access to behavioral health services but will end in December 2016 without legislative action |
|
|
Noted opposition to ACA but importance of considering expansion to make the best decisions for the state; current negotiations with federal officials to change reimbursement process for services provided to Indian Health Services enrollees could cover the state’s expansion costs; will not move forward on expansion without legislative budget authority or if any new general funds are needed; also detailed how cost projections for the expansion population were developed; encouraged any expansion legislation to include language to end expansion if the federal match is reduced |
|
|
Noted flaws of ACA but urged legislators to find a state-tailored solution to covering the uninsured |
|
|
Urged legislators to consider Medicaid expansion through a bipartisan, state-tailored solution |
|
|
Noted opposition to ACA overall but that state should craft tailored expansion plan; commented on loss of federal revenue from not expanding affecting hospitals and businesses, and uninsured individuals lacking coverage; cited many organizations that support expansion (e.g. state business alliance and chambers of commerce) |
Two governors spoke about the topic of the ACA’s exchanges in their speeches.
|
Mentioned plans to cease operations of the state’s exchange, Kynect, and that individuals will enroll through the federal exchange |
|
|
Noted improvements in eligibility determinations and access to the state’s Health Connector in the past year |
Health issues related to mental health and substance use disorders were the most commonly cited by governors in their speeches, with 26 governors mentioning these issues in some way. Governors’ frequently highlighted strategies that have been implemented or that they plan to implement to increase access to behavioral health services.
|
Highlighted the issue of drug addiction; plans to convene a group of experts on substance abuse issues, recovering addicts and providers to identify appropriate treatments and reduce barriers to care |
|
|
State is working to improve access to mental health care through State Innovation Model project; also plans to address links between suicide, mental illness and guns |
|
|
State has significantly increased access to substance use treatment and is working with law enforcement to address overdoses; budget includes funding to provide team-based care for individuals in need of intensive treatment services; also plans for the Department of Health and Social Services to work with primary care providers to identify substance abuse issues earlier |
|
|
Mentioned behavioral health issues as the underlying cause of many social, health and economic challenges and that mental health is the most pressing unmet health issue facing the state |
|
|
Local behavioral health crisis centers have been effective; proposed budget includes funding for an additional center |
|
|
Need to increase treatment options for drug addiction; will create task force on enforcement, treatment and prevention; also plans to build the first new mental health hospital in a generation |
|
|
Highlighted the importance of addressing the needs of individuals with severe mental illnesses; will be launching a crisis prevention program for individuals ages 21 to 35 with severe mental illnesses and substance use disorders |
|
|
Recent passage of state laws that increase access to substance abuse treatment; state still needs to “double down” on drug addiction and to treat it as an illness; committed to providing $100 million to improve access to mental health and substance use treatment by providing higher reimbursement rates for services and providers; plans to increase funding for three Accountable Care Organizations focused on providing coordinated physical and behavioral health treatment for Medicaid patients |
|
|
In the past five years the highest amount of funding in the state’s history has been provided for mental health; legislation was passed to reduce prescription drug and substance abuse fatalities |
|
|
Recent investments of over $700 million in the state’s mental health system to restore prior service cuts, but additional focus on the issue is still needed; proposed budget includes funding directed towards building a stronger mental health system |
|
|
Substance abuse has become one of the most significant challenges in the state; have invested in treatment services and resources to publicize services, updated prescription drug monitoring efforts, and implemented other measures to reduce the oversupply of pain medication |
Health issues related to mental health and substance use disorders were the most commonly cited by governors in their speeches, with 26 governors mentioning these issues in some way. The issue of heroin and other types of opioid abuse and overdoses were specifically mentioned by a number of governors in their remarks.
|
Recently passed state law allowing healthcare providers to make an antidote available to address opioid overdoses and to allow Medicaid to cover inpatient detoxification |
|
|
Plans to address heroin and opioid addiction; proposed budget includes funding for treatment programs and continuation of efforts to monitor prescription drugs |
|
|
State is working to address heroin and opioid addiction through a state-level task force |
|
|
Legislation being developed to address the heroin and opioid abuse epidemic by building capacity in prevention, education, and treatment efforts |
|
|
Need for a prescription drug monitoring program to address the opioid abuse epidemic |
|
|
State has worked to address the heroin and opioid abuse crisis but the issue remains the most urgent public health and public safety concern; efforts are underway to strengthen the state’s prescription drug monitoring program and improve access to treatment, but need further funding for law enforcement and efforts to strengthen prevention, treatment and recovery initiatives |
|
|
Plans to launch a treatment intervention pilot program for individuals recovering from drug overdoses; individuals in recovery will help lead the intervention programs |
|
|
State views opioid overdoses as a public health crisis; aiming to reduce overdoses by one-third in the next three years by investing in treatment, overdose reversals, prevention and recovery |
|
|
State has coordinated trainings for first responders on administering Narcan, an antidote for opioid overdoses; plans to introduce legislation to expand access to Narcan without a prescription |
|
|
Proposing funding to make a pilot program for overdose drug naloxone permanent; also funding for needle exchange programs, additional state staff resources and to develop a new treatment hub |
Health issues related to mental health and substance use disorders were the most commonly cited by governors in their speeches, with 26 governors mentioning these issues in some way. Governors spoke about the issue of behavioral health within the context of better addressing the needs of justice-involved individuals, and providing mental health and substance use treatment services rather than incarceration when appropriate.
|
Will be focusing on providing drug treatment and counseling to justice-involved individuals to help reduce recidivism |
|
|
Mentioned justice reforms have diverted justice-involved individuals with substance use disorders to treatment rather than incarceration when appropriate |
|
|
Bipartisan commission to reform the criminal justice system recommended enhancing cognitive behavioral therapy and substance abuse treatment programs in the corrections system |
|
|
As part of the state’s justice policy reforms, will be focusing on rehabilitation instead of incarceration and on looking at funding models for drug and mental health courts |
|
|
Proposing $1.6 million to reduce the number of severely mentally ill individuals cycling through jails and emergency rooms and to direct them to treatment instead |
|
|
With reductions in the state’s prison population, one of the correctional facilities has been closed and will be converted into a certified drug abuse treatment facility for justice-involved individuals |
|
|
Importance of addressing the behavioral health issues of justice-involved individuals; proposed budget includes funding for new crisis triage centers, mobile crisis response teams, and community behavioral health clinics |
|
|
State has significantly increased the number of drug and DUI courts; more non-violent justice-involved individuals are receiving community treatment rather than being incarcerated |
|
|
State has increased the number of drug recovery courts, resulting in reduced incarceration costs; proposing to invest more in these courts in order to offer services in all counties |
|
|
Need to address issue of individuals with severe mental illnesses who cycle between jails and emergency rooms; proposed budget includes funding for four new 16-bed crisis triage facilities and three new mobile crisis teams |
Five governors noted issues related to the health care workforce, primarily commenting on strategies to address shortages.
|
Mentioned physician and dentist shortage in nearly all of the state’s counties, and outlined plans to increase funding for medical scholarships and loan forgiveness for students committing to serve in underserved areas; also aims to create tax credits for rural providers and increase funding for 12 new residency programs |
|
|
Noted that programs to train individuals in the health care field are expanding |
|
|
Commented on need to address state’s lack of primary care physicians by maintaining funding for physician residency slots and providing medical loan reimbursement; also requests that the Board of Education work with the medical community and higher education institutions to develop plans to address the growing need for healthcare providers |
|
|
Mentioned current state legislation that would permit the state to enter into a compact with other states to allow medical licenses to be interchangeable across states |
|
|
Commented on how plans to expand employment training programs will help address healthcare workforce shortages; a task force will focus on developing innovative solutions to further address these shortages |
Some governors mentioned other specific health topics in their speeches, either as recent accomplishments or as future plans. These included topics such as enhancements to autism coverage, improvements in health coverage eligibility determinations, or lowered prison pharmacy costs.
|
Mentioned that state will be providing health care coverage to children of undocumented workers; also state leads the nation in providing Medicaid home-based care, which also gives jobs to health care providers |
|
|
Noted plans to partner with a national nonprofit organization to improve access to contraceptive options by offering better training for health care providers |
|
|
Mentioned that in recognition of the need for private sector resources for Maui’s public hospitals, recently transferred hospital management to Kaiser Permanente |
|
|
Will be forming a working group to address rural health care delivery issues |
|
|
Addressed the water crisis in Flint and proposes support for increasing children’s access to health care and treatment for health issues associated with elevated blood lead levels |
|
|
Highlighted passage of autism legislation to ensure that appropriate services are available through health plans; will expand services at existing autism centers and build a new center |
|
|
Mentioned improvements at state’s Department of Health and Human Services have streamlined low-income residents’ access to nutrition assistance and other assistance programs |
|
|
Mentioned that Department of Correction worked with TennCare to lower prison pharmacy costs annually by $5 million; proposed budget includes funding for a mobile seating and positioning unit in the Department of Intellectual and Developmental Disabilities |
|
|
Noting the importance of helping individuals cope with health and mental health care needs to retain workplace talent, mentioned a recently completed informational kit for employers to provide to employees caring for family members with dementia or Alzheimer’s disease |
Meeting the Health-Related Social Needs of Low-Income Persons: Funding Sources Available to States
The Accountable Health Communities initiative recently announced by the Center for Medicare & Medicaid Innovation (CMMI) holds promise for helping communities bridge the gap between health care and social services. This important work has the potential to improve health in communities by addressing food insecurity, housing instability, and other social determinants of health. Although the CMMI initiative is focused at the local level, states themselves have the capacity and the resources to scale up local innovation for the benefit of all state residents, regardless of where they live.
States control an array of resources that can be used to provide health care and address the social determinants of health. To assist state policymakers seeking to maximize their leverage by working across state agencies to promote health, NASHP has compiled a chart of funding sources that state agencies use to address social determinants, such as stable housing, safe and prosperous neighborhoods and communities, access to healthy food, physical and mental health care, income support, and transportation. While many documents show states how Medicaid resources can be used for social services or housing needs, this chart aims to bring attention to other funding sources that states use specifically to help adult high-cost/high-need residents live healthy and prosperous lives. Is your state breaking down silos to promote health across agencies and funding streams? Please share your examples with us at aclary@oldsite.nashp.org . Watch for additional NASHP resources for states on coordinating, braiding, and blending funding streams to improve health.
Download chart as PDF
Housing |
|
| National Housing Trust Fund (HTF) (U. S. Department of Housing and Urban Development [HUD]) | State housing departments or housing finance agencies |
| HOME Investment Partnerships Program Block Grants (U. S. Department of Housing and Urban Development) | Localities or State Housing and/or Community Development Authorities |
| Emergency Solutions Grants (U. S. Department of Housing and Urban Development) | State housing and/or community development authorities; localities |
| Continuum of Care Program (U. S. Department of Housing and Urban Development) | Applicants generally apply collectively by geographic area; state participants include State Housing and Finance Agencies. State and local governments and nonprofit organizations can apply. |
| Low Income Home Energy Assistance Program (LIHEAP) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | State housing, health and human services, community and economic development agencies |
| Low Income Housing Tax Credit (U. S. Department of Housing and Urban Development) | State housing finance agencies |
| Mortgage Revenue Bonds(Issued by states and localities, subject to Internal Revenue Service requirements) | State housing finance agencies |
Health |
|
| Medicaid (U. S. Centers for Medicare & Medicaid Services) | Medicaid agencies |
| Title V Maternal and Child Health Services Block Grant (U. S. Department of Health and Human Services Maternal & Child Health Bureau) | State health departments |
| Community Mental Health Services Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | State health departments |
| Substance Abuse Prevention and Treatment Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | State health departments |
| Preventive Health and Health Services Block Grant (U. S. Centers for Disease Control and Prevention)[1] | State health departments |
| State and Local Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke (U. S. Centers for Disease Control and Prevention) | State and local health departments award |
| Ryan White HIV/AIDS Program (Part B) (U. S. Health Resources and Services Administration) | State departments of health |
Community and Economic Development |
|
| Community Development Block Grant (CDBG)(U. S. Department of Housing and Urban Development) | State community and economic development agencies generally administer grants for smaller cities and counties which do not receive funds directly from HUD |
| Community Services Block Grant (CSBG) (U. S. Department of Health and Human Services Administration for Children and Families) | State community and economic development agencies |
| Child Care and Development Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | State human and social services agencies |
Income Support and Food Security |
|
| Social Services Block Grant (SSBG)(U. S. Department of Health and Human Services Administration for Children and Families) | State community and economic development agencies, and state human services agencies |
| Temporary Assistance for Needy Families (TANF) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | State departments of health and human services or social services |
| Supplemental Nutrition Assistance Program (SNAP) (U. S. Department of Agriculture Food and Nutrition Service) | State departments of health and human services |
| Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (U. S. Department of Agriculture Food and Nutrition Service) | State health departments |
| Child and Adult Care Food Program (U. S. Department of Agriculture Food and Nutrition Service) | State departments of education or departments of health or human services |
Transportation |
|
| Surface Transportation Program (U. S. Department of Transportation; from the Highway Trust Fund) | State Departments of Transportation |
Funding Sources Not Awarded Directly to States |
|
| Federal Reserve Banks: Pay for Success Programs and Social Impact Bonds | State community development, housing finance agencies, or other agencies could be involved |
| Hospital Community Benefit Requirements | Hospitals must comply with both federal and state (if any) community benefit requirements in order to maintain their tax exemptions. |
| Community Development Financial Institutions (CDFIs) | Can include credit unions and non-regulated private-sector financial institutions |
| Community Development Financial Institutions Fund (Treasury) | Funds credit unions, CDFIs, and other “mission-driven financial institutions,” not states |
| New Markets Tax Credit Programs (Treasury; Community Development Financial Institutions [CDFI] Fund)* *Federal funds are allocated to investment groups, not states, but many states operate their own NMTC programs. | State NMTC programs are administered by state finance authorities or development agencies |
Housing |
|
| National Housing Trust Fund (HTF) (U. S. Department of Housing and Urban Development [HUD]) | Very low and extremely low-income households, including homeless families |
| HOME Investment Partnerships Program Block Grants (U. S. Department of Housing and Urban Development) | Very-low and low-income people 90% of occupants of HOME-supported rental units generally must have incomes at or below 60% of area median income. (Section 92.216 of final rule) |
| Emergency Solutions Grants (U. S. Department of Housing and Urban Development) | The homeless and those at risk of homelessness (The definition of “homeless” for different purposes is codified in statute.) |
| Continuum of Care Program (U. S. Department of Housing and Urban Development) | Homeless individuals and families |
| Low Income Home Energy Assistance Program (LIHEAP) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | Low-income households, including renters |
| Low Income Housing Tax Credit (U. S. Department of Housing and Urban Development) | Low-income households |
| Mortgage Revenue Bonds(Issued by states and localities, subject to Internal Revenue Service requirements) | Lower-income first-time homebuyers |
Health |
|
| Medicaid (U. S. Centers for Medicare & Medicaid Services) | Lower income individuals |
| Title V Maternal and Child Health Services Block Grant (U. S. Department of Health and Human Services Maternal & Child Health Bureau) | Women and children, especially those with low income |
| Community Mental Health Services Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | Adults with serious mental illness and children with serious emotional disturbances |
| Substance Abuse Prevention and Treatment Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | Pregnant women, women with dependent children, IV drug users, those in need of TB and HIV services |
| Preventive Health and Health Services Block Grant (U. S. Centers for Disease Control and Prevention)[1] | Varies by state |
| State and Local Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke (U. S. Centers for Disease Control and Prevention) | Population-wide |
| Ryan White HIV/AIDS Program (Part B) (U. S. Health Resources and Services Administration) | Those testing positive for HIV; generally lower-income or uninsured people. Some states establish additional criteria. |
Community and Economic Development |
|
| Community Development Block Grant (CDBG)(U. S. Department of Housing and Urban Development) | Low- and moderate-income people 70% of funds go to cities and communities; 30% to states for use in smaller communities |
| Community Services Block Grant (CSBG) (U. S. Department of Health and Human Services Administration for Children and Families) | Low-income communities |
| Child Care and Development Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | Lower-income (income not exceeding 85% of state median) working (or attending school or training) families with children younger than age 13. |
Income Support and Food Security |
|
| Social Services Block Grant (SSBG)(U. S. Department of Health and Human Services Administration for Children and Families) | At state’s discretion. The program aims to promote economic self-sufficiency |
| Temporary Assistance for Needy Families (TANF) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | Needy families with children |
| Supplemental Nutrition Assistance Program (SNAP) (U. S. Department of Agriculture Food and Nutrition Service) | Low-income households |
| Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (U. S. Department of Agriculture Food and Nutrition Service) | Low-income pregnant and postpartum women, and children up to age 5 at nutritional risk |
| Child and Adult Care Food Program (U. S. Department of Agriculture Food and Nutrition Service) | Children in day care and adults in adult day care |
Transportation |
|
| Surface Transportation Program (U. S. Department of Transportation; from the Highway Trust Fund) | The general public |
Housing |
|
| National Housing Trust Fund (HTF) (U. S. Department of Housing and Urban Development [HUD]) | Primarily buying and developing affordable rental housing; some relocation costs, such as moving expenses. 10% can be used to promote homeownership. |
| HOME Investment Partnerships Program Block Grants (U. S. Department of Housing and Urban Development) | Tenant-based rental assistance, including rent and security deposits;Grants, loans or loan guarantees for construction or rehabilitation of rental housing, rehabilitation of owner-occupied housing, and assisting homebuyers and tenants. 60% to localities; 40% to states. (Section 92.205–92.212) |
| Emergency Solutions Grants (U. S. Department of Housing and Urban Development) | Emergency shelter, including costs associated with maintaining and operating an emergency shelter;Services associated with emergency shelter, including physical and mental health, employment, substance abuse and other services;Homelessness prevention and rapid re-housing, including rental assistance and utility and security deposits;Street outreach;Homeless Management Information Systems (HMIS) |
| Continuum of Care Program (U. S. Department of Housing and Urban Development) | Permanent housing, transitional housing, permanent supportive housing, rapid rehousing, supportive services, outreach, homelessness prevention, and Homeless Management Information Systems.Covers property acquisition, rehabilitation, construction, leasing costs, and rental assistance (42 USC 11383). |
| Low Income Home Energy Assistance Program (LIHEAP) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | Home heating and cooling Weatherization: replacing or repairing furnaces or air conditioners; installing insulation; fixing leaks in doors and windowsEnergy needs resulting from a natural disaster or emergency(See the Low-Income Home Energy Assistance Act) |
| Low Income Housing Tax Credit (U. S. Department of Housing and Urban Development) | Construction and rehabilitation of affordable rental housing that has a certain percentage of affordable units. |
| Mortgage Revenue Bonds(Issued by states and localities, subject to Internal Revenue Service requirements) | Low-cost mortgages for first-time homebuyersThe federal government authorizes state or local governments, or their housing finance agencies, to sell Mortgage Revenue Bonds to investors. The proceeds of the sale finances mortgages to eligible homebuyers |
Health |
|
| Medicaid (U. S. Centers for Medicare & Medicaid Services) | For most beneficiaries, states must cover medically necessary services, including hospital, lab, physician, non-emergency medical transportation, and other services. Services must generally be offered statewide, and adequate in amount, duration, and scope. |
| Title V Maternal and Child Health Services Block Grant (U. S. Department of Health and Human Services Maternal & Child Health Bureau) | A wide range of health care and related activities, including preventive and primary health care services for children, some childcare services, and assistance applying for services. |
| Community Mental Health Services Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | Comprehensive community mental health services, including screening, outpatient, and emergency services |
| Substance Abuse Prevention and Treatment Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | A range of activities to prevent and treat substance abuse, including primary prevention services for those at high risk for substance abuse |
| Preventive Health and Health Services Block Grant (U. S. Centers for Disease Control and Prevention) | A range of public health topics, including social determinants of health. The grant has funded walking trails, bicycle helmets, and water fluoridation, among other activities.The grant supports the priorities of Healthy People 2020 |
| State and Local Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke (U. S. Centers for Disease Control and Prevention) | Chronic disease prevention programs, focused in four areas: Epidemiology and surveillance; environmental strategies to promote healthy behaviors; health systems interventions, and community and clinical linkages. |
| Ryan White HIV/AIDS Program (Part B) (U. S. Health Resources and Services Administration) | Medication to treat HIV/AIDS; medical and support services and services to support HIV/AIDS treatment |
Community and Economic Development |
|
| Community Development Block Grant (CDBG)(U. S. Department of Housing and Urban Development) | A variety of activities related to economic development, neighborhood revitalization, housing rehabilitation and blight prevention.At least 70% of funds must benefit low- and moderate- income people. |
| Community Services Block Grant (CSBG) (U. S. Department of Health and Human Services Administration for Children and Families) | A range of poverty reduction and community development activities, based on community needs assessments. Examples can include emergency shelter and food programs, employment counseling, transportation programs, and activities for senior citizens and youth. |
| Child Care and Development Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | Subsidies for child care; child care program improvements |
Income Support and Food Security |
|
| Social Services Block Grant (SSBG)(U. S. Department of Health and Human Services Administration for Children and Families) | A wide range of activities in 29 service categories that promote self-sufficiency, prevent child abuse, and support “community-based care for the elderly and disabled (CRS).” Examples:· Child care, home maintenance, home-delivered meals, health support services, family planning, employment services, adoption and foster care, transportation, services for substance abuse |
| Temporary Assistance for Needy Families (TANF) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | Cash assistanceWork programsChild care & transportation aid for nonworking parentsPrograms, activities, and services “reasonably calculated” to achieve TANF’s four-fold purpose, per HHS ACF:(1) provide assistance to needy families so children can be cared for in their own homes; (2) Reduce the dependency of needy parents by promoting job preparation, work and marriage; (3) Prevent and reduce the incidence of out-of-wedlock pregnancies; and (4) encourage the formation and maintenance of two-parent families. |
| Supplemental Nutrition Assistance Program (SNAP) (U. S. Department of Agriculture Food and Nutrition Service) | Food for home preparation and consumption; seeds and plants to grow food at home |
| Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (U. S. Department of Agriculture Food and Nutrition Service) | Food, nutrition education, breastfeeding support, health and social service screening and referrals |
| Child and Adult Care Food Program (U. S. Department of Agriculture Food and Nutrition Service) | Meals meeting nutritional guidelines served to participants meeting income requirements for free or reduced-price meals |
Transportation |
|
| Surface Transportation Program (U. S. Department of Transportation; from the Highway Trust Fund) | Highways, transit infrastructure, bicycle transportation and pedestrian walkways |
Housing |
|
| National Housing Trust Fund (HTF) (U. S. Department of Housing and Urban Development [HUD]) | Transitional housing; counseling services (except for housing counseling paid for as an administrative cost); some costs for projects already underway when the HTF is implemented; (See p. 5208 of the Federal Register, Section 92.730 of the Preamble to the Interim Rule) |
| HOME Investment Partnerships Program Block Grants (U. S. Department of Housing and Urban Development) | Modernizing public housing, providing tenant-based rental assistance under theSection 8 program, supporting ongoing operational costs of rental housing, paying back taxes or fees on properties that are or will be assisted with HOME funds, and providing non-federal matching funds for any other federal program. (Section 92.214) |
| Emergency Solutions Grants (U. S. Department of Housing and Urban Development) | Services unrelated to street outreach emergency shelter, homelessness prevention, rapid re-housing assistance, HMIS, and administrative activities. (See Section 576.100 of Interim Rule) |
| Continuum of Care Program (U. S. Department of Housing and Urban Development) | Services not meeting the required criteria for reducing homelessness |
| Low Income Home Energy Assistance Program (LIHEAP) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | Water bills (unless used for air conditioning) or energy for other uses such as lightingPurchase of real estate |
| Low Income Housing Tax Credit (U. S. Department of Housing and Urban Development) | |
| Mortgage Revenue Bonds(Issued by states and localities, subject to Internal Revenue Service requirements) | Mortgages for those who are not first-time home buyers, or who earn more than the area median income (with an adjustment for large families) |
Health |
|
| Medicaid (U. S. Centers for Medicare & Medicaid Services) | Expenditures not allowable under federal rules.Waivers and state plan amendments can provide states with some flexibility. |
| Title V Maternal and Child Health Services Block Grant (U. S. Department of Health and Human Services Maternal & Child Health Bureau) | Cash payments to beneficiaries; purchase of medical equipment or real estate; most inpatient services (See 42 USC 704) |
| Community Mental Health Services Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | Financial assistance to private for-profit entities |
| Substance Abuse Prevention and Treatment Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | Financial assistance to private for-profit entities |
| Preventive Health and Health Services Block Grant (U. S. Centers for Disease Control and Prevention)[1] | Prohibited uses include inpatient care, cash payments to beneficiaries, real estate or construction, as a source of non-federal matching funds, and financial assistance to a private for-profit entity. |
| State and Local Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke (U. S. Centers for Disease Control and Prevention) | Prohibited uses include gun control promotion, needle exchange programs, dealings with corporations with felonies or tax debts, |
| Ryan White HIV/AIDS Program (Part B) (U. S. Health Resources and Services Administration) | Prohibited uses include real estate, construction, or cash payments to recipients of services |
Community and Economic Development |
|
| Community Development Block Grant (CDBG)(U. S. Department of Housing and Urban Development) | Ineligible activities generally include construction of new housing (with exceptions), some income payments, political activities, buildings to house “the general conduct of government” |
| Community Services Block Grant (CSBG) (U. S. Department of Health and Human Services Administration for Children and Families) | Real estate or construction; political activities |
| Child Care and Development Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | Prohibited uses include:Administrative costs exceeding 5% of a year’s allocationMost real estate purchases or constructionSectarian worship or instruction |
Income Support and Food Security |
|
| Social Services Block Grant (SSBG)(U. S. Department of Health and Human Services Administration for Children and Families) | Prohibited uses include:Land or capital improvements (may be waived)Room and board (with certain exceptions)WagesMost medical care (with some exceptions for family planning, rehab/detox, and medical care provided as an “integral but subordinate component of a social service”),Social services for people in institutionsEducational services available in public schools |
| Temporary Assistance for Needy Families (TANF) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | TANF block grant “assistance” has some limitations, such as a prohibition on payment for medical services in most cases.However, non-assistance aid can fund a broad range of services related to TANF’s four-fold purpose |
| Supplemental Nutrition Assistance Program (SNAP) (U. S. Department of Agriculture Food and Nutrition Service) | Hot food ready to eat (with some exceptions), alcohol, tobacco |
| Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (U. S. Department of Agriculture Food and Nutrition Service) | Food items that are not WIC-eligible |
| Child and Adult Care Food Program (U. S. Department of Agriculture Food and Nutrition Service) | The program will not approve reimbursement to state agencies for:Food served to someone not enrolled for adult or child careMeals not approved in the agreement or out of compliance with the approved meal pattern |
Transportation |
|
| Surface Transportation Program (U. S. Department of Transportation; from the Highway Trust Fund) | Some projects on non-federal, local or rural minor roads |
Housing |
|
| National Housing Trust Fund (HTF) (U. S. Department of Housing and Urban Development [HUD]) | Cannot require tenant to accept supportive services.All HTF-assisted units will be required to have a minimum affordability period of 30 years. (See Section 93.304 of the interim rule)Aligned with the HOME Investment Partnerships program regulationsNo state match is required, although the state allocation plan must consider the availability of non-federal funding as a priority factor for determining allocations. (See Section 92.220 of the interim rule) |
| HOME Investment Partnerships Program Block Grants (U. S. Department of Housing and Urban Development) | Most HOME grantees must match 25% of their grant with non-federal funds (Section 92.218 of Final Rule)Participating jurisdictions must reserve part of their HOME funding for Community Development Housing Organizations. (Section 92.300 of Final Rule) |
| Emergency Solutions Grants (U. S. Department of Housing and Urban Development) | States are required to match grant funds awards above a certain threshold |
| Continuum of Care Program (U. S. Department of Housing and Urban Development) | Grantees must match 25% of funds, except for leasing funds.Housing units acquired, built, or rehabilitated must be operated for the specified purpose for 15 years |
| Low Income Home Energy Assistance Program (LIHEAP) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | |
| Low Income Housing Tax Credit (U. S. Department of Housing and Urban Development) | Credits are allocated to states, who allocate them to developers, who sell them to investors, who finance low-income housing developments |
| Mortgage Revenue Bonds(Issued by states and localities, subject to Internal Revenue Service requirements) | There is an annual cap on the amount of bonds a state can issue |
Health |
|
| Medicaid (U. S. Centers for Medicare & Medicaid Services) | States pay for a portion of their Medicaid expenses. The state share varies from state to state based on per capita income and other factors. |
| Title V Maternal and Child Health Services Block Grant (U. S. Department of Health and Human Services Maternal & Child Health Bureau) | States must match every $4 of Title V funding with at least $3 in non-federal funds |
| Community Mental Health Services Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | Grantee states must have a mental health planning councilState maintenance of effort requirement |
| Substance Abuse Prevention and Treatment Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | State maintenance of effort requirementSpecified percentages of grant funds must be used for primary prevention; early HIV intervention; administration; and a SAMHSA “set-aside” for data collection, evaluation, and TA |
| Preventive Health and Health Services Block Grant (U. S. Centers for Disease Control and Prevention) | Maintenance of effort requirement |
| State and Local Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke (U. S. Centers for Disease Control and Prevention) | States sub-award half of the funds to 4-8 local communities |
| Ryan White HIV/AIDS Program (Part B) (U. S. Health Resources and Services Administration) | Some state must provide non-federal matching funds |
Community and Economic Development |
|
| Community Development Block Grant (CDBG)(U. S. Department of Housing and Urban Development) | States generally may not use the funds to directly undertake community development activities. States are pass-through agents that distribute funds to communities. |
| Community Services Block Grant (CSBG) (U. S. Department of Health and Human Services Administration for Children and Families) | States must pass at least 90% of CSBG funds to local entities. |
| Child Care and Development Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | Health and safety requirements for providersMost families contribute child care co-payments on a sliding scale. |
Income Support and Food Security |
|
| Social Services Block Grant (SSBG)(U. S. Department of Health and Human Services Administration for Children and Families) | No matching requirement for states |
| Temporary Assistance for Needy Families (TANF) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | States contribute their own funds in a maintenance-of-effort (MOE) requirementWork requirements for some adult recipients60-month time limit for adults |
| Supplemental Nutrition Assistance Program (SNAP) (U. S. Department of Agriculture Food and Nutrition Service) | SNAP benefits may only be used at certain retailersMost able-bodied recipients must meet work or training requirements |
| Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (U. S. Department of Agriculture Food and Nutrition Service) | States participating in the Farmers Market Nutrition Program must pay for at least 30% of the program’s administrative costs |
| Child and Adult Care Food Program (U. S. Department of Agriculture Food and Nutrition Service) |
Transportation |
|
| Surface Transportation Program (U. S. Department of Transportation; from the Highway Trust Fund) | States and localities generally pay for the 20% of a project not covered by the federal share. States and localities generally pay 10% of interstate projectsNote: states also contribute significantly to transportation funding through gas and vehicle taxes and other sources. |
Housing |
|
| National Housing Trust Fund (HTF) (U. S. Department of Housing and Urban Development [HUD]) | States prepare an annual allocation plan (See Section 91.220 of the interim rule)Annual audits |
| HOME Investment Partnerships Program Block Grants (U. S. Department of Housing and Urban Development) | To be awarded funds, submit a Consolidated Plan covering a 3- to 5-year period describing housing needs and how HOME funds will be used to meet those needs and attract non-federal funds for affordable housing.Annually, submit a performance report describing the year’s activities, progress to date, and use of funds. |
| Emergency Solutions Grants (U. S. Department of Housing and Urban Development) | Grant recipients submit a Consolidated Plan and annual performance reports |
| Continuum of Care Program (U. S. Department of Housing and Urban Development) | Annual Report to Congress |
| Low Income Home Energy Assistance Program (LIHEAP) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | Grantees report annually |
| Low Income Housing Tax Credit (U. S. Department of Housing and Urban Development) | Tax credit documents are filed with the IRS |
| Mortgage Revenue Bonds(Issued by states and localities, subject to Internal Revenue Service requirements) | Subject to IRS requirements |
Health |
|
| Medicaid (U. S. Centers for Medicare & Medicaid Services) | States report budget and expenditure data |
| Title V Maternal and Child Health Services Block Grant (U. S. Department of Health and Human Services Maternal & Child Health Bureau) | Annual reporting on outcome and performance measures, and narrative of program impact. |
| Community Mental Health Services Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | Annual reporting; federal monitoring visits to some states |
| Substance Abuse Prevention and Treatment Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | Annual reporting, including reporting on national outcome measures |
| Preventive Health and Health Services Block Grant (U. S. Centers for Disease Control and Prevention)[1] | Annual reporting requirements |
| State and Local Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke (U. S. Centers for Disease Control and Prevention) | Annual reporting, including the Prevention and Public Health Fund reporting requirements |
| Ryan White HIV/AIDS Program (Part B) (U. S. Health Resources and Services Administration) | Annual reporting requirements |
Community and Economic Development |
|
| Community Development Block Grant (CDBG)(U. S. Department of Housing and Urban Development) | Uses the HUD consolidated planning process. Annual action plan and a performance evaluation report detailing its progress toward the goals identified in the action plan. The evaluation report must include information on the racial, ethnic, and income status of people benefiting from the funds. |
| Community Services Block Grant (CSBG) (U. S. Department of Health and Human Services Administration for Children and Families) | Annual state assessments; monitoring visits to some states |
| Child Care and Development Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | States must make electronically available the results of monitoring and inspection results for child care providersQuarterly, annual, and biennial reporting requirements |
Income Support and Food Security |
|
| Social Services Block Grant (SSBG)(U. S. Department of Health and Human Services Administration for Children and Families) | States submit an annual intended use plan and post-expenditure report |
| Temporary Assistance for Needy Families (TANF) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | · States submit three quarterly reports and an annual report |
| Supplemental Nutrition Assistance Program (SNAP) (U. S. Department of Agriculture Food and Nutrition Service) | Included in annual Schedule of Expenditures of Federal Awards (SEFA) |
| Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (U. S. Department of Agriculture Food and Nutrition Service) | Annual reporting and evaluation requirements |
| Child and Adult Care Food Program (U. S. Department of Agriculture Food and Nutrition Service) | Annual reportingUnannounced site visits at least once every three years |
Funding Sources Not Awarded Directly to States |
|
| Federal Reserve Banks: Pay for Success Programs and Social Impact Bonds | Based on the terms of the program |
| Hospital Community Benefit Requirements | Annual reporting to IRS on Schedule H of Form 990 to maintain tax-exempt status |
| Community Development Financial Institutions (CDFIs) | |
| Community Development Financial Institutions Fund (Treasury) | |
| New Markets Tax Credit Programs (Treasury; Community Development Financial Institutions [CDFI] Fund)* *Federal funds are allocated to investment groups, not states, but many states operate their own NMTC programs. | Community Development Entities certify their status with Treasury’s CDFI fundNMTC grantees report to IRS |
[1] States spending $500,000 or more of federal awards per year must file a single audit reporting on federal programs.
Housing |
|
| National Housing Trust Fund (HTF) (U. S. Department of Housing and Urban Development [HUD]) | HUD expects to award funds by summer 2016. HUD is required to grant each state and DC a minimum allocation. |
| HOME Investment Partnerships Program Block Grants (U. S. Department of Housing and Urban Development) | $1 billion appropriated nationwide in FY2014, according to the Congressional Research Services (CRS).According to HUD, “HOME is the largest Federal block grant to state and local governments designed exclusively to create affordable housing for low-income households.” |
| Emergency Solutions Grants (U. S. Department of Housing and Urban Development) | $250 million nationwide appropriated for FY2014, according to CRS |
| Continuum of Care Program (U. S. Department of Housing and Urban Development) | Total allocation for 2014 nationwide: $1.8 billion |
| Low Income Home Energy Assistance Program (LIHEAP) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | $3.4 billion appropriated for the block grant nationwide in FY2014; $3.36 billion for FY2015 |
| Low Income Housing Tax Credit (U. S. Department of Housing and Urban Development) | It gives the equivalent of $8 billion in tax credits annually. According to HUD, “The Low-Income Housing Tax Credit (LIHTC) is the most important resource for creating affordable housing in the United States today.” |
| Mortgage Revenue Bonds(Issued by states and localities, subject to Internal Revenue Service requirements) | The National Council of State Housing Agencies estimates that Mortgage Revenue Bonds make first-time homeownership possible for approximately 100,000 families each year |
Health |
|
| Medicaid (U. S. Centers for Medicare & Medicaid Services) | The federal government’s share of Medicaid expenditures totaled $299 billion in FY2014, according to CRS. |
| Title V Maternal and Child Health Services Block Grant (U. S. Department of Health and Human Services Maternal & Child Health Bureau) | $630 million appropriated nationwide in FY2014, according to CRS |
| Community Mental Health Services Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | FY2014 appropriation was $480 million nationwide, per CRS |
| Substance Abuse Prevention and Treatment Block Grant (U. S. Substance Abuse and Mental Health Services Administration) | FY2014 appropriation was $1.8 billion, per CRS. SAMHSA writes that this block grant accounts for roughly 29% of public funds spent on substance abuse services. |
| Preventive Health and Health Services Block Grant (U. S. Centers for Disease Control and Prevention)[1] | $160 million appropriated for FY2014 |
| State and Local Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke (U. S. Centers for Disease Control and Prevention) | $33 million in new funds for 2014. Financed by the Affordable Care Act’s Prevention and Public Health Fund |
| Ryan White HIV/AIDS Program (Part B) (U. S. Health Resources and Services Administration) | Funded at $2.32 billion as of October 2014 |
Community and Economic Development |
|
| Community Development Block Grant (CDBG)(U. S. Department of Housing and Urban Development) | According to CRS, over $3 billion was allocated nationwide in FY 2013. In that year, the CDBG was the largest source of federal funding for community development, and the 20th largest source of federal assistance to state and local governments. |
| Community Services Block Grant (CSBG) (U. S. Department of Health and Human Services Administration for Children and Families) | According to CRS, $709 million was appropriated for FY2014. TheFY 2015 White House budget proposed $350 million for CSBG nationwide |
| Child Care and Development Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | $2.36 billion discretionary funding appropriation and $2.9 billion in mandatory appropriation for FY2014, per CRS. |
Income Support and Food Security |
|
| Social Services Block Grant (SSBG)(U. S. Department of Health and Human Services Administration for Children and Families) | $1.57 billion appropriated for FY2014, according to CRS |
| Temporary Assistance for Needy Families (TANF) Block Grant (U. S. Department of Health and Human Services Administration for Children and Families) | FY2014 appropriation was $17.3 billion nationwide, according to CRS |
| Supplemental Nutrition Assistance Program (SNAP) (U. S. Department of Agriculture Food and Nutrition Service) | According to CRS, in 2014, more than 46 million individuals participated in SNAP, and the federal government spent more than $70 million on benefits nationwide |
| Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (U. S. Department of Agriculture Food and Nutrition Service) | $6.6 billion as of September 2015 |
| Child and Adult Care Food Program (U. S. Department of Agriculture Food and Nutrition Service) | $3 billion obligated for FY2014, according to CRS |
Transportation |
|
| Surface Transportation Program (U. S. Department of Transportation; from the Highway Trust Fund) | $10 billion appropriated nationwide in FY2014, according to CRS |
Funding Sources Not Awarded Directly to States |
|
| Federal Reserve Banks: Pay for Success Programs and Social Impact Bonds | Social Impact Bonds address social services or social issues. The specific project and criteria for success are outlined in the contract between parties.Government contracts with an entity to provide services, and pays the entity based on their performance. The entity raises private and philanthropic capital for operations. Investors are paid back with the entity’s pay for performance funds, if any. |
| Hospital Community Benefit Requirements | Services and activities to support the health or safety of the communities served by the hospitals. “Community building activities” can include child care services; housing rehabilitation; the provision of housing for certain patients after discharge; construction or maintenance of parks and playgrounds; economic development activities; public health emergency readiness activities; environmental improvements, such as addressing pollution and garbage.The ACA also requires tax-exempt hospitals to conduct a community health needs assessment once every three years and plan a strategy to implement it.IRS requirements for tax-exempt hospitals describe the activities and services that satisfy the hospital community benefit requirements.Hospitals can count the uncompensated and charity care as community benefit activities. |
| Community Development Financial Institutions (CDFIs) | Mortgage financing, bond funding and commercial loans in low-income communities |
| Community Development Financial Institutions Fund (Treasury) | Financing for affordable housing services, economic development services, consumer credit counseling and financial education |
| New Markets Tax Credit Programs (Treasury; Community Development Financial Institutions [CDFI] Fund)* *Federal funds are allocated to investment groups, not states, but many states operate their own NMTC programs. | Permits individual and corporate taxpayers to receive a federal income tax credit for making Qualified Equity Investments (QEIs) in qualified community development entities (CDEs).Cannot pay for things outside the scope of the Treasury programLegislation is pending to indefinitely extend the federal NMTC program.$3.5 billion in NMTCs allocated for CY2014 |
Note: Other CDC support is available to states and localities, often targeted at specific conditions. Such support includes state-based tobacco control programs, the National Asthma Control Program, and a number of HIV–related demonstrations.
Overview of Funding: Meeting the Health-Related Social Needs of Low-income Persons
National Housing Trust Fund (HTF)
|
|
| State Agency or Entity | State housing departments or housing finance agencies |
| Population served | Very low and extremely low-income households, including homeless families |
| What it pays for | Primarily buying and developing affordable rental housing; some relocation costs, such as moving expenses. 10% can be used to promote homeownership. |
| What it cannot pay for | Transitional housing; counseling services (except for housing counseling paid for as an administrative cost); some costs for projects already underway when the HTF is implemented; (See p. 5208 of the Federal Register, Section 92.730 of the Preamble to the Interim Rule) |
| Strings attached | Cannot require tenant to accept supportive services.All HTF-assisted units will be required to have a minimum affordability period of 30 years. (See Section 93.304 of the interim rule)Aligned with the HOME Investment Partnerships program regulationsNo state match is required, although the state allocation plan must consider the availability of non-federal funding as a priority factor for determining allocations. (See Section 92.220 of the interim rule) |
| Accountability | States prepare an annual allocation plan (See Section 91.220 of the interim rule)Annual audits |
| Magnitude | HUD expects to award funds by summer 2016. HUD is required to grant each state and DC a minimum allocation. |
HOME Investment Partnerships Program Block Grants
|
|
| State Agency or Entity | Localities or State Housing and/or Community Development Authorities |
| Population served | Very-low and low-income people90% of occupants of HOME-supported rental units generally must have incomes at or below 60% of area median income. (Section 92.216 of final rule) |
| What it pays for | Tenant-based rental assistance, including rent and security deposits;Grants, loans or loan guarantees for construction or rehabilitation of rental housing, rehabilitation of owner-occupied housing, and assisting homebuyers and tenants. 60% to localities; 40% to states. (Section 92.205–92.212) |
| What it cannot pay for | Modernizing public housing, providing tenant-based rental assistance under theSection 8 program, supporting ongoing operational costs of rental housing, paying back taxes or fees on properties that are or will be assisted with HOME funds, and providing non-federal matching funds for any other federal program. (Section 92.214) |
| Strings attached | Most HOME grantees must match 25% of their grant with non-federal funds (Section 92.218 of Final Rule)Participating jurisdictions must reserve part of their HOME funding for Community Development Housing Organizations. (Section 92.300 of Final Rule) |
| Accountability | To be awarded funds, submit Consolidated Plan covering a 3- to 5-year period describing housing needs and HOME funds will be used to meet those needs and attract non-federal funds for affordable housing.Annually, submit a performance report describing the year’s activities, progress to date, and use of funds. |
| Magnitude | $1 billion appropriated nationwide in FY2014, according to the Congressional Research Services (CRS).According to HUD, “HOME is the largest Federal block grant to state and local governments designed exclusively to create affordable housing for low-income households.” |
Emergency Solutions Grants
|
|
| State Agency or Entity | State housing and/or community development authorities; localities |
| Population served | The homeless and those at risk of homelessness (The definition of “homeless” for different purposes is codified in statute.) |
| What it pays for | Emergency shelter, including costs associated with maintaining and operating an emergency shelter;Services associated with emergency shelter, including physical and mental health, employment, substance abuse and other services;Homelessness prevention and rapid re-housing, including rental assistance and utility and security deposits;Street outreach;Homeless Management Information Systems (HMIS) |
| What it cannot pay for | Services unrelated to street outreach emergency shelter, homelessness prevention, rapid re-housing assistance, HMIS, and administrative activities. (See Section 576.100 of Interim Rule) |
| Strings attached | States are required to match grant funds awards above a certain threshold |
| Accountability | Grant recipients submit a Consolidated Plan and annual performance reports |
| Magnitude | $250 million nationwide appropriated for FY2014, according to CRS |
Continuum of Care Program
|
|
| State Agency or Entity | Applicants generally apply collectively by geographic area; state participants include State Housing and Finance Agencies. State and local governments and nonprofit organizations can apply. |
| Population served | Homeless individuals and families |
| What it pays for | Permanent housing, transitional housing, permanent supportive housing, rapid rehousing, supportive services, outreach, homelessness prevention, and Homeless Management Information Systems.Covers property acquisition, rehabilitation, construction, leasing costs, and rental assistance (42 USC 11383). |
| What it cannot pay for | Services not meeting the required criteria for reducing homelessness |
| Strings attached | Grantees must match 25% of funds, except for leasing funds.Housing units acquired, built, or rehabilitated must be operated for the specified purpose for 15 years |
| Accountability | Annual Report to Congress |
| Magnitude | Total allocation for 2014 nationwide: $1.8 billion |
Low Income Home Energy Assistance Program (LIHEAP) Block Grant
|
|
| State Agency or Entity | State housing, health and human services, community and economic development agencies |
| Population served | Low-income households, including renters |
| What it pays for | Home heating and coolingWeatherization: replacing or repairing furnaces or air conditioners; installing insulation; fixing leaks in doors and windowsEnergy needs resulting from a natural disaster or emergency(See the Low-Income Home Energy Assistance Act) |
| What it cannot pay for | Water bills (unless used for air conditioning) or energy for other uses such as lightingPurchase of real estate |
| Strings attached | |
| Accountability | Grantees report annually |
| Magnitude | $3.4 billion appropriated for the block grant nationwide in FY2014; $3.36 billion for FY2015 |
Low Income Housing Tax Credit
|
|
| State Agency or Entity | State housing finance agencies |
| Population served | Low-income households |
| What it pays for | Construction and rehabilitation of affordable rental housing that has a certain percentage of affordable units. |
| What it cannot pay for | |
| Strings attached | Credits are allocated to states, who allocate them to developers, who sell them to investors, who finance low-income housing developments |
| Accountability | Tax credit documents are filed with the IRS |
| Magnitude | It gives the equivalent of $8 billion in tax credits annually. According to HUD, “The Low-Income Housing Tax Credit (LIHTC) is the most important resource for creating affordable housing in the United States today.” |
Mortgage Revenue Bonds
|
|
| State Agency or Entity | State housing finance agencies |
| Population served | Lower-income first-time homebuyers |
| What it pays for | Low-cost mortgages for first-time homebuyersThe federal government authorizes state or local governments, or their housing finance agencies, to sell Mortgage Revenue Bonds to investors. The proceeds of the sale finances mortgages to eligible homebuyers |
| What it cannot pay for | Mortgages for those who are not first-time home buyers, or who earn more than the area median income (with an adjustment for large families) |
| Strings attached | There is an annual cap on the amount of bonds a state can issue |
| Accountability | Subject to IRS requirements |
| Magnitude | The National Council of State Housing Agencies estimates that Mortgage Revenue Bonds make first-time homeownership possible for approximately 100,000 families each year |
Medicaid (U. S. Centers for Medicare & Medicaid Services) |
|
| State Agency or Entity | Medicaid agencies |
| Population served | Lower income individuals |
| What it pays for | For most beneficiaries, states must cover medically necessary services, including hospital, lab, physician, non-emergency medical transportation, and other services. Services must generally be offered statewide, and adequate in amount, duration, and scope. |
| What it cannot pay for | Expenditures not allowable under federal rules.Waivers and state plan amendments can provide states with some flexibility. |
| Strings attached | States pay for a portion of their Medicaid expenses. The state share varies from state to state based on per capita income and other factors. |
| Accountability | States report budget and expenditure data |
| Magnitude | The federal government’s share of Medicaid expenditures totaled $299 billion in FY2014, according to CRS. |
Title V Maternal and Child Health Services Block Grant
|
|
| State Agency or Entity | State health departments |
| Population served | Women and children, especially those with low income |
| What it pays for | A wide range of health care and related activities, including preventive and primary health care services for children, some child care services, and assistance applying for services. |
| What it cannot pay for | Cash payments to beneficiaries; purchase of medical equipment or real estate; most inpatient services (See 42 USC 704) |
| Strings attached | States must match every $4 of Title V funding with at least $3 in non-federal funds |
| Accountability | Annual reporting on outcome and performance measures, and narrative of program impact. |
| Magnitude | $630 million appropriated nationwide in FY2014, according to CRS |
Community Mental Health Services Block Grant
|
|
| State Agency or Entity | State health departments |
| Population served | Adults with serious mental illness and children with serious emotional disturbances |
| What it pays for | Comprehensive community mental health services, including screening, outpatient, and emergency services |
| What it cannot pay for | Financial assistance to private for-profit entities |
| Strings attached | Grantee states must have a mental health planning councilState maintenance of effort requirement |
| Accountability | Annual reporting; federal monitoring visits to some states |
| Magnitude | FY2014 appropriation was $480 million nationwide, per CRS |
Substance Abuse Prevention and Treatment Block Grant
|
|
| State Agency or Entity | State health departments |
| Population served | Pregnant women, women with dependent children, IV drug users, those in need of TB and HIV services |
| What it pays for | A range of activities to prevent and treat substance abuse, including primary prevention services for those at high risk for substance abuse |
| What it cannot pay for | Financial assistance to private for-profit entities |
| Strings attached | State maintenance of effort requirementSpecified percentages of grant funds must be used for primary prevention; early HIV intervention; administration; and a SAMHSA “set-aside” for data collection, evaluation, and TA |
| Accountability | Annual reporting, including reporting on national outcome measures |
| Magnitude | FY2014 appropriation was $1.8 billion, per CRS. SAMHSA writes that this block grant accounts for roughly 29% of public funds spent on substance abuse services. |
Preventive Health and Health Services Block Grant
|
|
| State Agency or Entity | State health departments |
| Population served | Varies by state |
| What it pays for | A range of public health topics, including social determinants of health. The grant has funded walking trails, bicycle helmets, and water fluoridation, among other activities.The grant supports the priorities of Healthy People 2020 |
| What it cannot pay for | Prohibited uses include inpatient care, cash payments to beneficiaries, real estate or construction, as a source of non-federal matching funds, and financial assistance to a private for-profit entity. |
| Strings attached | Maintenance of effort requirement |
| Accountability | Annual reporting requirements |
| Magnitude | $160 million appropriated for FY2014 |
State and Local Public Health Actions to Prevent Obesity, Diabetes, Heart Disease, and Stroke (U. S. Centers for Disease Control and Prevention) |
|
| State Agency or Entity | State and local health departments award |
| Population served | Population-wide |
| What it pays for | Chronic disease prevention programs, focused in four areas: Epidemiology and surveillance; environmental strategies to promote healthy behaviors; health systems interventions, and community and clinical linkages. |
| What it cannot pay for | Prohibited uses include gun control promotion, needle exchange programs, dealings with corporations with felonies or tax debts |
| Strings attached | States sub-award half of the funds to 4-8 local communities |
| Accountability | Annual reporting, including the Prevention and Public Health Fund reporting requirements |
| Magnitude | $33 million in new funds for 2014. Financed by the Affordable Care Act’s Prevention and Public Health Fund |
Ryan White HIV/AIDS Program (Part B)
|
|
| State Agency or Entity | State departments of health |
| Population served | Those testing positive for HIV; generally lower-income or uninsured people. Some states establish additional criteria. |
| What it pays for | Medication to treat HIV/AIDS; medical and support services and services to support HIV/AIDS treatment |
| What it cannot pay for | Prohibited uses include real estate, construction, or cash payments to recipients of services |
| Strings attached | Some state must provide non-federal matching funds |
| Accountability | Annual reporting requirements |
| Magnitude | Funded at $2.32 billion as of October 2014 |
Community Development Block Grant (CDBG)
|
|
| State Agency or Entity | State community and economic development agencies generally administer grants for smaller cities and counties which do not receive funds directly from HUD |
| Population served | Low- and moderate-income people70% of funds go to cities and communities; 30% to states for use in smaller communities |
| What it pays for | A variety of activities related to economic development, neighborhood revitalization, housing rehabilitation and blight prevention.At least 70% of funds must benefit low- and moderate- income people. |
| What it cannot pay for | Ineligible activities generally include construction of new housing (with exceptions), some income payments, political activities, buildings to house “the general conduct of government” |
| Strings attached | States generally may not use the funds to directly undertake community development activities. States are pass-through agents that distribute funds to communities. |
| Accountability | Uses the HUD consolidated planning process. Annual action plan and a performance evaluation report detailing its progress toward the goals identified in the action plan. The evaluation report must include information on the racial, ethnic, and income status of people benefiting from the funds. |
| Magnitude | According to CRS, over $3 billion was allocated nationwide in FY 2013. In that year, the CDBG was the largest source of federal funding for community development, and the 20th largest source of federal assistance to state and local governments. |
Community Services Block Grant (CSBG)
|
|
| State Agency or Entity | State community and economic development agencies |
| Population served | Low-income communities |
| What it pays for | A range of poverty reduction and community development activities, based on community needs assessments. Examples can include emergency shelter and food programs, employment counseling, transportation programs, and activities for senior citizens and youth. |
| What it cannot pay for | Real estate or construction; political activities |
| Strings attached | States must pass at least 90% of CSBG funds to local entities. |
| Accountability | Annual state assessments; monitoring visits to some states |
| Magnitude | According to CRS, $709 million was appropriated for FY2014. TheFY 2015 White House budget proposed $350 million for CSBG nationwide |
Child Care and Development Block Grant
|
|
| State Agency or Entity | State human and social services agencies |
| Population served | Lower-income (income not exceeding 85% of state median) working (or attending school or training) families with children younger than age 13. |
| What it pays for | Subsidies for child care; child care program improvements |
| What it cannot pay for | Prohibited uses include:Administrative costs exceeding 5% of a year’s allocationMost real estate purchases or constructionSectarian worship or instruction |
| Strings attached | Health and safety requirements for providersMost families contribute child care co-payments on a sliding scale. |
| Accountability | States must make electronically available the results of monitoring and inspection results for child care providersQuarterly, annual, and biennial reporting requirements |
| Magnitude | $2.36 billion discretionary funding appropriation and $2.9 billion in mandatory appropriation for FY2014, per CRS. |
Social Services Block Grant (SSBG)
|
|
| State Agency or Entity | State community and economic development agencies, and state human services agencies |
| Population served | At state’s discretion. The program aims to promote economic self-sufficiency |
| What it pays for | A wide range of activities in 29 service categories that promote self-sufficiency, prevent child abuse, and support “community-based care for the elderly and disabled (CRS).” Examples:
|
| What it cannot pay for | Prohibited uses include:Land or capital improvements (may be waived)Room and board (with certain exceptions)WagesMost medical care (with some exceptions for family planning, rehab/detox, and medical care provided as an “integral but subordinate component of a social service”),Social services for people in institutionsEducational services available in public schools |
| Strings attached | No matching requirement for states |
| Accountability | States submit an annual intended use plan and post-expenditure report |
| Magnitude | $1.57 billion appropriated for FY2014, according to CRS |
Temporary Assistance for Needy Families (TANF) Block Grant
|
|
| State Agency or Entity | State departments of health and human services or social services |
| Population served | Needy families with children |
| What it pays for | Cash assistanceWork programsChild care & transportation aid for nonworking parentsPrograms, activities, and services “reasonably calculated” to achieve TANF’s four-fold purpose, per HHS ACF:(1) provide assistance to needy families so children can be cared for in their own homes; (2) Reduce the dependency of needy parents by promoting job preparation, work and marriage; (3) Prevent and reduce the incidence of out-of-wedlock pregnancies; and (4) encourage the formation and maintenance of two-parent families. |
| What it cannot pay for | TANF block grant “assistance” has some limitations, such as a prohibition on payment for medical services in most cases.However, non-assistance aid can fund a broad range of services related to TANF’s four-fold purpose |
| Strings attached | States contribute their own funds in a maintenance-of-effort (MOE) requirementWork requirements for some adult recipients60 month time limit for adults |
| Accountability | States submit three quarterly reports and an annual report |
| Magnitude | FY2014 appropriation was $17.3 billion nationwide, according to CRS |
Child and Adult Care Food Program
|
|
| State Agency or Entity | State departments of education or departments of health or human services |
| Population served | Children in day care and adults in adult day care |
| What it pays for | Meals meeting nutritional guidelines served to participants meeting income requirements for free or reduced-price meals |
| What it cannot pay for | The program will not approve reimbursement to state agencies for:Food served to someone not enrolled for adult or child careMeals not approved in the agreement or out of compliance with the approved meal pattern |
| Strings attached | |
| Accountability | Annual reportingUnannounced site visits at least once every three years |
| Magnitude | $3 billion obligated for FY2014, according to CRS |
Supplemental Nutrition Assistance Program (SNAP)
|
|
| State Agency or Entity | State departments of health and human services |
| Population served | Low-income households |
| What it pays for | Food for home preparation and consumption; seeds and plants to grow food at home |
| What it cannot pay for | Hot food ready to eat (with some exceptions), alcohol, tobacco |
| Strings attached | SNAP benefits may only be used at certain retailersMost able-bodied recipients must meet work or training requirements |
| Accountability | Included in annual Schedule of Expenditures of Federal Awards (SEFA) |
| Magnitude | According to CRS, in 2014, more than 46 million individuals participated in SNAP, and the federal government spent more than $70 million on benefits nationwide |
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
|
|
| State Agency or Entity | State health departments |
| Population served | Low-income pregnant and postpartum women, and children up to age 5 at nutritional risk |
| What it pays for | Food, nutrition education, breastfeeding support, health and social service screening and referrals |
| What it cannot pay for | Food items that are not WIC-eligible |
| Strings attached | States participating in the Farmers Market Nutrition Program must pay for at least 30% of the program’s administrative costs |
| Accountability | Annual reporting and evaluation requirements |
| Magnitude | $6.6 billion as of September 2015 |
Surface Transportation Program
|
|
| State Agency or Entity | State departments of transportation |
| Population served | The general public |
| What it pays for | Highways, transit infrastructure, bicycle transportation and pedestrian walkways |
| What it cannot pay for | Some projects on non-federal, local or rural minor roads |
| Strings attached | States and localities generally pay for the 20% of a project not covered by the federal share. States and localities generally pay 10% of interstate projectsNote: states also contribute significantly to transportation funding through gas and vehicle taxes and other sources. |
| Accountability | |
| Magnitude | $10 billion appropriated nationwide in FY2014, according to CRS |
The role of the state in the below programs varies. However, the programs listed below have the potential to align with and support state health goals and initiatives.
Federal Reserve Banks: Pay for Success Programs and Social Impact Bonds |
|
| State Agency or Entity | State community development, housing finance agencies, or other agencies could be involved |
| Population served | Varies by project |
| Purpose | Social Impact Bonds address social services or social issues. The specific project and criteria for success are outlined in the contract between parties.Government contracts with an entity to provide services, and pays the entity based on their performance. The entity raises private and philanthropic capital for operations. Investors are paid back with the entity’s pay for performance funds, if any. |
| Accountability | Based on the terms of the program |
Hospital Community Benefit Requirements |
|
| State Agency or Entity | Hospitals must comply with both federal and state (if any) community benefit requirements in order to maintain their tax exemptions. |
| Population served | The communities served by the hospital |
| Purpose | Services and activities to support the health or safety of the communities served by the hospitals. “Community building activities” can include child care services; housing rehabilitation; the provision of housing for certain patients after discharge; construction or maintenance of parks and playgrounds; economic development activities; public health emergency readiness activities; environmental improvements, such as addressing pollution and garbage.The ACA also requires tax-exempt hospitals to conduct a community health needs assessment once every three years and plan a strategy to implement it.IRS requirements for tax-exempt hospitals describe the activities and services that satisfy the hospital community benefit requirements.Hospitals can count the uncompensated and charity care as community benefit activities. |
| Accountability | Annual reporting to IRS on Schedule H of Form 990 to maintain tax-exempt status |
Community Development Financial Institutions (CDFIs) |
|
| State Agency or Entity | Can include credit unions and non-regulated private-sector financial institutions |
| Population served | Low-income individuals and communities |
| Purpose | Mortgage financing, bond funding and commercial loans in low-income communities |
| Accountability | |
Community Development Financial Institutions Fund (Treasury) |
|
| State Agency or Entity | Funds credit unions, CDFIs, and other “mission-driven financial institutions,” not states |
| Population served | Primarily low income populations |
| Purpose | Financing for affordable housing services, economic development services, consumer credit counseling and financial education |
| Accountability | |
New Markets Tax Credit Programs
|
|
| State Agency or Entity | State NMTC programs are administered by state finance authorities or development agencies |
| Population served | Low-income communities or populations |
| Purpose | Permits individual and corporate taxpayers to receive a federal income tax credit for making Qualified Equity Investments (QEIs) in qualified community development entities (CDEs).Cannot pay for things outside the scope of the Treasury programLegislation is pending to indefinitely extend the federal NMTC program.$3.5 billion in NMTCs allocated for CY2014 |
| Accountability | Community Development Entities certify their status with Treasury’s CDFI fundNMTC grantees report to IRS |
Note: Other CDC support is available to states and localities, often targeted at specific conditions. Such support includes state-based tobacco control programs, the National Asthma Control Program, and a number of HIV–related demonstrations.
Population Health Components of State Innovation Model (SIM) Plans: Round 2 Model Testing States
The Round Two State Innovation Model (SIM) Test Awards granted by HHS to eleven states (Colorado, Connecticut, Delaware, Idaho, Iowa, Michigan, New York, Rhode Island, Ohio, Tennessee, and Washington) support state efforts to build multi-payer models of health system transformation. As noted in a previous analysis, population health improvement is an important component of the SIM awards. The SIM Funding Opportunity Announcement (FOA) required states to describe how their models would improve population health in a number of areas, including prevention, health equity and the social determinants of health, rates of obesity and diabetes, and healthy behaviors, including reduced tobacco use. The FOA also required states to incorporate new delivery system models into their population health improvement plans.
This chart contains population health strategies, as defined by the states, that the states plan to implement through their SIM Round Two Model Test initiatives. The information in the chart is derived from the states’ proposals and other documents that you will find linked in the text below. Information on the population health components of the Round One SIM Model Test Awards can be found in our previous SIM population health chart. Please note that because the information in these charts was abstracted from early documents, we anticipate that this information may change as the states implement their models.
We encourage our community to share and discuss more details, ideas, issues and emerging products and results on State Refor(u)m. Do you know of state activity or analyses that we should add to this chart? Eager to update a fact we’ve included? Your contributions are central to our community’s ongoing, real-time learning, so tell us in a comment below, or email aclary@oldsite.nashp.org with your suggestions.
We encourage our community to share and discuss more details, ideas, issues and emerging products and results on State Refor(u)m. Do you know of state activity or analyses that we should add to this chart? Eager to update a fact we’ve included? Your contributions are central to our community’s ongoing, real-time learning, so tell us in a comment below, or email aclary@oldsite.nashp.org with your suggestions.
| Population Health Objectives in the Model | Strategies in the Model to Address Social, Economic, and Behavioral Determinants of Health and Health Equity | Engaging and Integrating Community Health and Prevention into Delivery System and Payment Reform Models | Population Health Metrics Used in Model | Strategies in the Model to Integrate Primary Care and Mental Health and Substance Abuse Disorder Services | |
|---|---|---|---|---|---|
| Colorado | Colorado seeks to improve population health by establishing a close partnership between public health, behavioral health, and primary care, and prioritizing ten population health focus areas including obesity, substance use, and mental health (SIM p.1). | Colorado state agencies are collaborating to address the social determinants of health using a “life stages” approach to targeting resources. The plan will include data collection on disparities in tobacco use, diabetes, and obesity (SIM p. 2, 11, 62). | Colorado will examine the possibility of long-term reimbursement models for population-based prevention and wellness services (SIM p. 25).Population Health Transformation Collaboratives made up of community health leaders will work with the state’s new Health Extension Service on local community health initiatives (SIM p. 4-5, 10). Targeted local public health agencies will receive funding for community prevention activities and to link practices, community resources, and public health (SIM p. 2). | Colorado will collect data on the progress in 12 core population health target areas:hypertension, obesity, tobacco use, prevention, asthma, diabetes, ischemic vascular disease, safety, depression, anxiety, substance use, safety, and child development (SIM p. 7-8). | The program’s shared risk and savings payment model will incentivize integrated physical and behavioral health services (SIM p. 2, 12-13, 23). A child mental health coordinator will develop prevention and early intervention programs for mental health challenges in children (SIM p. 5-7). |
| Connecticut | Connecticut plans to strengthen primary care and integrate community and clinical care. It also aims to improve prevention and screening, including mental health and substance abuse screening, and chronic illness management (SIM p. 1; 22-23). | Connecticut will convene a multi-sector Population Health Council tasked with setting priorities for health improvement areas, focusing on the barriers most likely to contribute to health disparities. The Health Enhancement Communities initiative focuses resources on the areas of the state with greatest disparities and will include payment incentives to address social determinants of health (SIM p. 2-3). The Equity and Access Council watches for under-service that may result from shared savings incentives. | Connecticut plans to develop sustainable Prevention Service Centers (PSCs) that will offer community-based preventive services. Reimbursement for Community Health Workers (CHWs) may also be part of the plan (SIM p. 2-3; 8). The state will also augment its use of Value-Based Insurance Design (VBID) and shared savings programs to incentivize prevention, health improvement, and management of chronic diseases (SIM p. 8, 12). | Connecticut will report measures for statewide population health targets including tobacco use, obesity, and diabetes (SIM p. 25). The plan also includes quality targets on preventive screenings, asthma, and premature death from cardio-vascular disease. The state will monitor equity gaps on core measures and select areas for improvement (SIM p. 26-28). | The model will complement the state’s existing Behavioral Health Home initiative, which coordinates physical and mental healthcare for Medicaid recipients with serious and persistent mental illness (SIM p. 29). |
| Delaware | Delaware aims to integrate population health with value-based payment models. It seeks to attribute every patient to a primary care provider (PCP) who is incentivized to address population health issues (SIM p. 1-8). | Delaware emphasizes cross-agency collaboration as part of its strategy to address social determinants of health. Also, as part of its Healthy Neighborhoods strategy, the Delaware Division of Public Health (DPH) will support staff health equity training (SIM p. 5-6). | Delaware’s Healthy Neighborhoods strategy seeks to enlist schools, employers, and community organizations in changing health behaviors. The plan will support a multi-stakeholder community coalition focused on identifying and addressing health needs (SIM p. 1-6). | The proposed population health metrics include measures related to smoking; nutrition; physical activity; prevalence of hypertension, obesity, and diabetes; cancer deaths per 100,000; heart disease deaths; 30-day post-PCI mortality rate; and infant mortality (SIMp. 37). | Delaware’s model will focus on providing team-based, integrated physical and behavioral health care for high-risk patients, including by providing incentives for EHR use to behavioral health providers. It will complement the existing PROMISE program that coordinates care for beneficiaries with mental illness. |
| Idaho | Idaho will develop a plan to improve population health by integrating population health with primary care and the healthcare delivery system through the use of Patient-Centered Medical Homes (PCMHs) covering 80% of the population (SIM p. 2-4). | Idaho is also planning a virtual PCMH telehealth initiative to serve remote communities. The state’s seven public health districts will also form Regional Collaboratives to integrate public and physical health locally to improve access to care. Idaho will collect data on the social determinants of health as part of a statewide health assessment. | PCMH providers will be allowed to practice at the top of their license to ameliorate workforce shortages. Telehealth initiatives and models for using CHWs and community health emergency medical services personnel in health promotion will also be explored (SIM p. 5-6). | Idaho will use the following population health performance measures to monitor the success of the Model Test: depression, tobacco use, asthma ED visits, hospitalizations, hospital readmissions, avoidable ED use without hospitalization, elective deliveries, low birth weight, adherence to antipsychotic meds for people with schizophrenia, weight counseling for children and adolescents, diabetes, childhood immunizations, adult BMI, and rate of prescribed opioid use for non-cancer pain. Idaho will also collect data on costs and patient experience of care (SIM p. 22-23). | PCHMs will coordinate care with Medical Neighborhoods of ancillary providers, including behavioral health providers. The state’s multi-payer common performance measures include screening for depression, adherence to antipsychotics for people with schizophrenia, and rates of prescribed opioid use for non-cancer pain. |
| Iowa | Iowa will build upon its existing ACO model to improve performance in six population health priority areas, including tobacco use, obesity, prevention and health literacy (SIMp. 1-3). The state’s plan also seeks to use ACOs to integrate public health providers with acute care delivery systems. | Iowa will provide support and technical assistance to encourage ACOs to develop workforce models, including telehealth, that address provider shortages and reduce the disparities between rural and urban areas (SIM p. 1). New Community Care Teams will connect ACOs with social services and local public health resources to address social determinants of health. Value-based payments will also incentivize ACOs to address the social determinants of health (SIM p. 12-15). | Iowa’s model seeks to expand care delivery into the community setting, and will track communities’ progress on population health initiatives. Community Care Teams will integrate public health and local ACOs to improve outcomes, and will facilitate connections with non-ACO providers (SIM p. 12-13). | Iowa will measure progress in six population health target areas: reducing tobacco use, obesity, hospital-associated infections, and early elective deliveries; and improving patient engagement and health literacy, including diabetes self-management (SIM p. 3-5). | Iowa will continue to incorporate behavioral health providers into its ACO structures, including the use of integrated health homes for individuals with mental illness (SIM p. 7-11). |
| Michigan | Michigan plans to improve wellness and reduce health risks on a population level through the use of Community Health Innovation Regions. PCMHs and integrated care networks called Accountable Systems of Care are also key elements (Blueprint p. 4-6). | Michigan is considering payment models that incentivize efforts to address social & environmental determinants of health. They are also planning greater use of and support for Community Health Workers to help reduce disparities (Blueprint p. 10-11, 37-41, 131-135). | Michigan’s Community Health Innovation Regions will work with local public health and cross-sector partners to engage patients and community members in wellness and health promotion activities. Michigan will also explore sustainable financing models for population-level prevention and wellness efforts. Michigan will also seek to allow providers to practice at the top of their license and training to increase access to primary care (Blueprint p. 4-5, 10, 132, 157). | Michigan’s plan includes monitoring access to primary care, clinical quality, patient experience of care, utilization, and other measures from the Michigan Health and Wellness dashboard, including measures related to birth outcomes and teen birth rates, obesity, alcohol consumption, nutrition, physical activity rate, tobacco use, dental health, mental health, STDs (Blueprint p. 72-75; p. 146-151). | Michigan plans to integrate behavioral health providers into person-centered health care teams. (Blueprint p. 126-127). |
| New York | New York’s plan has five primary population health goals:1. Prevent Chronic Disease2. Promote Healthy and Safe Environments 3. Promote Healthy Women, Infants and Children 4. Promote Mental Health and Prevent Substance Abuse; and 5. Prevent HIV, STDs, Vaccine-Preventable Diseases and Healthcare Associated Infections (SIM p. 1). |
New York’s plan will support population health, preventive services, and integrated behavioral primary care through its advanced primary care medical home model, and through the use of SIM-funded public health consultants and practice transformation teams (SIM p. 1-2). | New York aims to pay for 80% of advanced primary care under a value-based payment model. Further, the project’s Public Health Consultants will also connect the community with public health and clinical resources (SIM p. 2-3). The state will also work to ensure that providers are practicing at the top of their license to improve access to care. | The project, including the advanced primary care model, will be evaluated according to an evolving statewide set of industry-standard quality and efficiency metrics, which includes progress toward prevention and public health goals (SIM p. 20-21). | New York will focus on integrating primary and behavioral health care, and will convene a workgroup to analyze gaps in behavioral health services and make recommendations. Initiatives supported by the new Public Health Consultants may include tobacco cessation for people with mental illness and other efforts to address mental illness and substance abuse disorders (SIM p. 2, 4,7). |
| Ohio | Ohio plans to target the prevention or reduction of obesity, chronic disease, tobacco use and exposure, and infant mortality; and plans to expand patient-centered primary care (SIM p. 5). | Ohio is testing ways to share data to improve population health, such as building on its current ability to use vital statistics data to indicate when a mother or infant may be at risk of poor health outcomes (SIM p. 6). | Ohio’s episode-based payment model and statewide use of PCMHs are intended to incent providers to work with community-based and public health resources to address social determinants of health (SIM p. 12). | Ohio’s SIM outcome metrics will include population health measures such as flu immunization and tobacco use, as well as care coordination and chronic conditions measures. Measures will be aligned across quality initiatives (SIM p. 24-28). | Ohio merged the formerly separate departments overseeing mental health and substance use disorders. The state is focused on integrated, person-centered care and care coordination for Medicaid beneficiaries with mental illness and other populations (SIM p. 5). |
| Rhode Island | With the help of community leaders, Rhode Island will develop a population-based plan that responds to the results of community health assessments, and continues efforts to reduce tobacco use and obesity and improve diabetes care management (SIM p. 4; SHIPp. 80-87). | Rhode Island will work with the community to develop community-driven goals for the healthcare system, and use Community Health Teams to help community organizations coordinate with primary care practices to support healthy lifestyles and address the social and environmental determinants of health and health disparities (SHIP p. 69, 75; SIM p. 4-5). | Rhode Island will rely on input from community-based leadership to guide the transformation of Rhode Island’s care delivery system, which will emphasize primary care and patient-centered medical homes, with Community Health Teams focusing on rising-risk and high-risk populations (SIM p. 4-5, 8; SHIP p. 63, 100). | Increasing prevention activities, statewide quality measurement and patient engagement tools are included in Rhode Island’s plan (SHIP p. 73-74), as are reducing over-utilization of unnecessary services, increasing screening and prevention, reducing health disparities, and renewing focus on the social determinants of health, among other aims (SHIP p. 94, 110). | Rhode Island will build on current efforts to integrate behavioral health and primary care through the use of health homes and co-location (SHIP p. 90; SIM p. 8). |
| Tennessee | Tennessee seeks to improve population health in five priority areas: obesity, diabetes, tobacco, child health, and perinatal health (SIM p. 2, 13). | PCMH providers will be incentivized to address social determinants of health through activities such as addressing environmental asthma triggers, tobacco cessation, and connecting patients to social services (SIM p. 4). Tennessee’s project will also facilitate the sharing of real-time hospital Admitting/ Discharge /Transfer (ADT) data with primary care providers and care coordinators to analyze gaps in care and prioritize resources for the most at-risk patients. | Tennessee plans a population-based, multi-payer patient-centered medical home initiative that will incentivize prevention and primary care. PCMHs will be evaluated on outcomes such as preventing avoidable ED visits and hospitalizations, controlling diabetes and high blood pressure, and screening for depression (SIM p. 22). | At minimum, Tennessee will measure the program’s impact on rates of child immunization, self-reported health status, tobacco use, obesity, and the proportion of diabetics with 2 or more A1C tests in the past year (SIM p. 25-26). | Tennessee will integrate its SIM funding and Health Homes initiative to provide integrated, value-based “behavioral and primary care services for people with Severe and Persistent Mental Illness (SPMI)” (SIM p. 7). |
| Washington | Washington plans to reduce tobacco use, obesity and diabetes, and increase the portion of the population who receive clinical and community services that reduce preventable conditions (SIM p. 5-6). | Washington will implement regional Accountable Communities of Health (ACH) to integrate the delivery of social services and healthcare services. ACHs will work across sectors, aligning housing, education, local government and the private sector to advance population health and address the social determinants of health (SIM p. 2, 6). Washington also plans to increase the number of communities with environments that promote physical and behavioral health and health equity (SIM p. 5). | Washington plans to engage “individuals, families, and communities” in a system that “supports social and health needs,” as well as improve the health of 90% of Washington residents and their communities by 2019 through prevention and early mitigation of disease (SIM p. 5, 26). | Washington will develop a statewide set of core measures that includes tobacco use, obesity and diabetes (SIM p. 6). It will also incorporate the “Results Washington”performance targets, including children’s vaccination rates, reducing preterm birth and cesarean section rates, increasing the number of residents with a personal healthcare provider, and increasing rates of services for post-discharge mental health consumers (SIM p. 27). | By 2020, Washington will require integrated physical and behavioral healthcare purchasing (SIM p. 10-11). |
Download PDF
Notes:
Chart produced by Amy Clary
Chart produced by Amy Clary
According to U.S. Census Bureau Report, Uninsured Rates Drop in All 50 States and Washington, DC
Health insurance numbers released from the U.S. Census Bureau show decreases in the rate of the uninsured in all 50 states and the District of Columbia. These numbers, which cover calendar year 2013 and calendar year 2014, allow us for the first time to look at how the policies of the Affordable Care Act have affected the nation’s overall insurance rate.
The state-by-state breakdown shows that Massachusetts continues to have the lowest uninsured rate in the country, with just 3.3 percent of its population reporting no insurance coverage in 2014. A review of the uninsured rates across all 50 states show that those states that opted to expand Medicaid and/or ran their own marketplace (or worked closely with the federal government on marketplace planning) saw the greatest decreases in the uninsured. Of the 14 State-based Marketplaces, only one chose not to expand Medicaid; of the 27 states that elected to use the federally facilitated marketplace, only four elected to expand. States with already low insurance rates, many of which were offering robust Medicaid programs prior to 2014, saw moderate but important decreases, as uninsured rates dipped below six percent in the District of Columbia, Hawaii, Minnesota, and Vermont.
| STATE | 2013 UNINSURED RATE | 2014 UNINSURED RATE | % Change |
| State-based Marketplace* | |||
| California | 17.2 | 12.4 | -28% |
| Colorado | 14.1 | 10.3 | -27% |
| Connecticut | 9.4 | 6.9 | -27% |
| DC | 6.7 | 5.3 | -21% |
| Hawaii | 6.7 | 5.3 | -21% |
| Idaho | 16.2 | 13.6 | -16% |
| Kentucky | 14.3 | 8.5 | -41% |
| Maryland | 10.2 | 7.9 | -23% |
| Massachusetts | 3.7 | 3.3 | -11% |
| Minnesota | 8.2 | 5.9 | -28% |
| New York | 10.7 | 8.7 | -19% |
| Oregon° | 14.7 | 9.7 | -34% |
| Rhode Island | 11.6 | 7.4 | -36% |
| Vermont | 7.2 | 5.0 | -31% |
| Washington | 14.0 | 9.2 | -34% |
| State-based Marketplaces that use the federal marketplace IT solution** | |||
| Nevada | 20.7 | 15.2 | -27% |
| New Mexico | 18.6 | 14.5 | -22% |
| Federally Facilitated Partnership*** | |||
| Arkansas | 16 | 11.8 | -26% |
| Delaware | 9.1 | 7.8 | -14% |
| Illinois | 12.7 | 9.7 | -24% |
| Iowa | 8.1 | 6.2 | -23% |
| Michigan | 11 | 8.5 | -23% |
| New Hampshire | 10.7 | 9.2 | -14% |
| West Virginia | 14 | 8.6 | -39% |
| Federally Facilitated Marketplace**** | |||
| Alabama | 13.6 | 12.1 | -11% |
| Alaska | 18.5 | 17.2 | -7% |
| Arizona | 17.1 | 13.6 | -20% |
| Florida | 20 | 16.6 | -17% |
| Georgia | 18.8 | 15.8 | -16% |
| Indiana | 14 | 11.9 | -15% |
| Kansas | 12.3 | 10.2 | -17% |
| Louisiana | 16.6 | 14.8 | -11% |
| Maine | 11.2 | 10.1 | -10% |
| Mississippi | 17.1 | 14.5 | -15% |
| Missouri | 13 | 11.7 | -10% |
| Montana | 16.5 | 14.2 | -14% |
| Nebraska | 11.3 | 9.7 | -14% |
| New Jersey | 13.2 | 10.9 | -17% |
| North Carolina | 15.6 | 13.1 | -16% |
| North Dakota | 10.4 | 7.9 | -24% |
| Ohio | 11 | 8.4 | -24% |
| Oklahoma | 17.7 | 15.4 | -13% |
| Pennsylvania | 9.7 | 8.5 | -12% |
| South Carolina | 15.8 | 13.6 | -14% |
| South Dakota | 11.3 | 9.8 | -13% |
| Tennessee | 13.9 | 12 | -14% |
| Texas | 22.1 | 19.1 | -14% |
| Utah | 14 | 12.5 | -11% |
| Virginia | 12.3 | 10.9 | -11% |
| Wisconsin | 9.1 | 7.3 | -20% |
| Wyoming | 13.4 | 12 | -10% |
* State-based marketplaces: States assume all responsibility for operation and maintenance of a marketplace.
**State-based marketplace using the federal marketplace IT solution: A state that is operating its own marketplace, but requests that CMS performs eligibility and enrollment functions using federal IT systems.
*** Federally facilitated partnership: CMS is responsible for establishing and operating the eligibility and enrollment and financial management functions, while the state assists with the plan management and/or consumer assistance.
**** Federally facilitated marketplace: Federal government assumes all responsibility for operation and maintenance of a marketplace.
° During the first open enrollment, Oregon had its own state platform and performed as an SBM. For the second open enrollment period (for coverage for 2015), Oregon elected to instead use the federal platform for its eligibility and enrollment, but continues to perform other SBM functions.
Retail Enrollment Centers
With the ACA’s introduction of open enrollment periods for health coverage programs, the time was right for innovative outreach models to reach new populations. Retail enrollment centers (also called “pop-up retail shops”) were one outreach and enrollment tool developed by states that has shown early promising results. In the first two years of ACA open enrollment periods, at least three state-based exchange (SBE) states (Connecticut, Colorado, and Kentucky) created retail enrollment centers. State officials interviewed reported a number of positive impacts from enrollment center experience, including increased visibility, improved outreach impact, a greater than average effectuation rate due to motivated and prepared consumers getting the help they need in a one-stop shop, and ensuring an accessible, central, community-based location to support enrollment. In this chart, we’ve captured information from three states that successfully used pop-up retail shops to inform other states that may be considering them for future years.
The states featured in this chart have demonstrated how to quickly build effective retail enrollment centers. As SBMs, the Connecticut, Colorado, and Kentucky exchanges were uniquely situated to reach target populations and try dynamic, innovative outreach methods to increase enrollment. SBMs have more centralized control over multiple aspects of outreach and enrollment processes than other states because the responsibility and authority for outreach is housed within the SBM, allowing the SBM the ability to tailor communications to the unique enrollment and assistance landscape, opportunities and challenges facing that specific state.
NASHP gathered information to create this chart through key informant interviews, email queries to state officials, and research supported by the Robert Wood Johnson Foundation’s Enrollment 2014 project, a one year project in which NASHP interviewed state leaders and stakeholders in 10 states with early success in enrollment and supported engagement of FFM state officials in Medicaid, CHIP, and Insurance/Exchange agencies. Although the information below reflects the step-by-step considerations of building pop-up shops for outreach and enrollment into health coverage programs by SBE agencies, other state agencies may also use this model to develop retail enrollment centers for other programs. Has your state also used a retail enrollment center approach? Please let us know – we welcome information from other states with similar experience.
The states featured in this chart have demonstrated how to quickly build effective retail enrollment centers. As SBMs, the Connecticut, Colorado, and Kentucky exchanges were uniquely situated to reach target populations and try dynamic, innovative outreach methods to increase enrollment. SBMs have more centralized control over multiple aspects of outreach and enrollment processes than other states because the responsibility and authority for outreach is housed within the SBM, allowing the SBM the ability to tailor communications to the unique enrollment and assistance landscape, opportunities and challenges facing that specific state.
NASHP gathered information to create this chart through key informant interviews, email queries to state officials, and research supported by the Robert Wood Johnson Foundation’s Enrollment 2014 project, a one year project in which NASHP interviewed state leaders and stakeholders in 10 states with early success in enrollment and supported engagement of FFM state officials in Medicaid, CHIP, and Insurance/Exchange agencies. Although the information below reflects the step-by-step considerations of building pop-up shops for outreach and enrollment into health coverage programs by SBE agencies, other state agencies may also use this model to develop retail enrollment centers for other programs. Has your state also used a retail enrollment center approach? Please let us know – we welcome information from other states with similar experience.
| State | State Exchange Structure | Number/ Location of Stores; Hours of Operation; Selection Process | Staffing | Operational Costs & Expenses | Physical Plant | Number of People Enrolled at Stores; ROI | Development Timeline |
|---|---|---|---|---|---|---|---|
| CO | State Agency: Colorado Health Benefit ExchangeExchange Name: Connect for Health ColoradoStructure:Public non-profit established by state law |
Number/ Location: 1 store in Downtown Denver (Years 1 and 2) (1) Operating Hours: M-F: 10am-6pm Sat: 12pm-6pm Closed Sunday (except on open enrollment deadline)Location Selection:
|
Positions:
Note:Usually 4-5 workers at store
|
Operational Costs: $16,000 rental$42,314 operational (furniture, wifi, signage, security, etc.) Additional Expenses: Night security (amount not provided) |
Machinery/ Technology: Repurposed staff laptops & work cell phones; no new equipment purchased Retail Space: 2,000 sq. ft. 4 month lease (Nov. 1-Feb. 28) Process for Establishing:
|
Enrolled: 238 enrolled1,055 assisted (not including individuals who called or were assisted but didn’t want to be tracked) ROI:(2)$206.06 per enrollee$55 per customer assisted 2
Other Benefits:
|
Planning: Work-plan fully developed 3 months prior to launch Physical Plant: Scouted physical locations 2 months prior to launch; finalized location 1 month before launch Staffing:1 month to plan; planning began 3 months prior to launch Identified sign-up tool to fill unique shifts by brokers, navigators, and staff |
| CT | State Agency: Connecticut Health Insurance Exchange Exchange Name:Structure:Quasi-public entity established bystate law |
Number/ Location: 2 stores: New Haven & Hartford (Year 1) Operating Hours:10am-8pm most days Location Selection:
|
Staff Positions:
Staff Shifts:
|
Outfitting Stores: $136,000 for both stores Operating Budget (Per Year): $140,000 (not including staff time) |
Machinery/ Technology: 20 laptops per store (only about 15 in use at a time) Retail Space: 2,200 sq. ft each; 1-year lease Acquisition:Real estate agent helped survey properties/select space
Process for Establishing:
|
Enrolled: 7,639 enrolled15,191 assisted ROI:(3)$36 per enrollment$18 per individual assisted
Other Benefits:
|
Planning: **Physical Plant:**Staffing: ** |
| KY | State Agency:Exchange Name: Structure: | Number/ Location: 1 store in Fayette Mall, Lexington, KY (Year 2) Operating Hours:10am-9am (mall hours) Location Selection:
|
Positions:
|
Outfitting Stores: $60,000 (including reusable materials) Operating Budget (Per Year):Under $100,000 |
Machinery/ Technology:
Note:connectors and agents used their own equipment. 1540 sq. ft.; 4 mo. lease (Nov. – Feb.) Worked with a marketing firm and advertisements; approached the mall about a temporary lease.
|
Enrolled: Over 5,900 enrolled7,600 visited the store ROI:$27 per enrollment$21 per assisted
Other Benefits:
|
Planning: 2 months to plan; planning began 3 months prior to launch Physical Plant: 1 month to install fixtures and prepare physical plant (after the design/layout was finalized); began 1 month prior to launch Staffing:2 months of planning prior to launch; ongoing changes during first weeks of operation; by 6 weeks following launch the staffing plan was finalized |
Notes:
(1) Connect for Health Colorado also worked with five other retail centers staffed by other organizations. This chart only tracks the center fully run and operated by state agency staff.
(2) ROI determined by dividing overall cost by number of people helped ($58,000/1,055=$55); however, this ROI does not reflect actual cost per person assisted given larger volume of individuals that were helped not tracked in the system.
(3) Estimated based on $276 total annual costs divided by number of individuals enrolled or assisted. Note that this does not take into account the staff time invested in developing and supporting the center.
(4) Added consumer representative role 1 month after launch, upon realizing consumers needed help at the beginning of the process to route them to the right assisters for help.
(2) ROI determined by dividing overall cost by number of people helped ($58,000/1,055=$55); however, this ROI does not reflect actual cost per person assisted given larger volume of individuals that were helped not tracked in the system.
(3) Estimated based on $276 total annual costs divided by number of individuals enrolled or assisted. Note that this does not take into account the staff time invested in developing and supporting the center.
(4) Added consumer representative role 1 month after launch, upon realizing consumers needed help at the beginning of the process to route them to the right assisters for help.
What Governors Are Saying About King v. Burwell
Last week’s ruling in King v. Burwell affirmed the provision of tax-subsidies through the federally-facilitated marketplace (FFM), a decision which may have affected over 6.4 million Americans currently receiving subsidies in the 34 states that have opted for the FFM model. The ruling has asserted the place of the Affordable Care Act (ACA), with state leaders continuing to play a critical role in determining how to implement the law most beneficially for the citizens of their states. Statements issued by governors in light of the ruling hint at the future direction of potential reforms across states. Read More As documented in this NASHP chart, 14 governors have released statements supporting the ruling, with comments emphasizing how the ruling improves access and continuity of coverage and lowers uninsured rates. Ten governors struck a more neutral tone, stating that the decision maintained the current status of coverage. Sixteen governors clearly opposed the Court’s ruling, with comments calling for an overhaul or repeal of the Affordable Care Act and suggestions to replace the law with options to give states greater flexibility and employ market-based reforms. In addition to weighing in on the ruling, several governors used this platform to advocate for related health care priorities. Governors in Alaska, Missouri and Virginia called for the legislature to pass Medicaid expansion; while those in Michigan and New Hampshire drew attention to alternate coverage expansion plans. Governors in New Hampshire, North Carolina, South Carolina, and Wyoming called for a focus on state flexibility and options to assure affordability and access to care for their citizens. Several governors from states operating state-based marketplaces (SBM) (Connecticut, Idaho, Kentucky, Nevada, and Rhode Island) said the decision affirmed that that the SBM was an appropriate marketplace model to benefit the citizens of their states. The ruling underscores that the ACA was built on a foundation of state innovation and experimentation; similar opportunities await as governors, along with other state leaders, debate future reforms in their states. NASHP will continue to track state activity around the King v. Burwell decision and support state leaders as they develop and advance reforms. If you have feedback or more you’d like to add to our chart, please email ccousart@oldsite.nashp.org. *Health Insurance Marketplace Models
State
Governor (Political Affiliation)
Quote
Health Insurance Marketplace Model*
Medicaid Expansion Status
AK
Walker (I)
“We are pleased so many of our friends, family and neighbors will be able to continue to receive health care. Now it’s important that we continue to work toward Medicaid expansion, so more Alaskans can receive the health coverage they need.” More…
FFM
No
AL
Bentley (R)
“I, as a physician, have always believed, that the Affordable Care Act is deeply flawed and does little to help improve the health of our citizens.” More…
FFM
No
AR
Hutchinson (R)
“We will continue our work…to find innovative solutions for Medicaid and healthcare reform. I am convinced now more than ever that we need to proceed with caution to measure the costs to the taxpayers and the reliability of the outcome as we consider the potential of a state exchange.” More…
SPM
Yes1
AZ
Ducey (R)
“[The ACA] isn’t the right plan for Arizona or for America, and it should be replaced.” More…
FFM
Yes
CA
Brown (D)
“Because of this ruling, health insurance continues to be accessible to every American, making our entire nation healthier and more prosperous.” More…
SBM
Yes
CT
Malloy (D)
“Today reminds us why we’re so proud to have built the best exchange in the nation…we embraced the Affordable Care Act, celebrated healthcare reform, and stood for progress by helping insure over 250,000 Connecticut residents.” More…
SBM
Yes
DE
Markell (D)
“For the more than 19,000 Delawareans who qualify, the federal subsidies are critical in helping to make health insurance more affordable. And we know that coverage is an important component in connecting Delawareans to care.” More…
SPM
Yes
FL
Scott (R)
“It’s a bad law. It was supposed to reduce health care costs and health care costs have gone up.” More…
FFM
No
IA
Branstad (R)
“The increasing costs of healthcare due to Obamacare red-tape and burdensome regulations have already led to tighter budgets for Iowa families….Obamacare continues to be unaffordable, unsustainable and unpredictable.” More…
FFM
Yes1
ID
Otter (R)
“Due to the wise and prudent course set by the governor and Legislature to ensure Idaho implemented our own state-run exchange, Idaho would not have been directly impacted by the court’s decision in either direction.” More…
SBM
No
IN
Pence (R)
“ObamaCare must be repealed and states must be given the flexibility to craft market-based solutions focused on lowering the cost of health care rather than growing the size of government.” More…
FFM
Yes1
KS
Brownback (R)
“Kansans will continue to suffer higher health care costs….We are hopeful that Congress and President Obama’s administration will provide states the needed flexibility in finding Kansas solutions to our health care challenges.” More…
FFM
No
KY
Beshear (D)
“The U.S. Supreme Court’s decision…reaffirms that, from the very start, we did the right thing for the more than 500,000 Kentuckians who have qualified for healthcare coverage through kynect since January 1, 2014.” More…
SBM
Yes
LA
Jindal (R)
“The debate will continue because the law has failed to accomplish its prime objective: Containing health care costs.” More…
FFM
No
MI
Snyder (R)
“Our focus can now center on securing the second waiver for our Healthy Michigan Plan, which has been an outstanding success. ” More…
SPM
Yes1
MN
Dayton (D)
“We need a period of stability now where we can improve upon the system that’s been established. I really hope the critics will recognize now that this is the system has been enacted. It’s federal law, and we’re going to work to make it better.” More…
SBM
Yes
MO
Nixon (D)
“Today’s ruling…removes all doubt that the ACA is and will remain the law of the land. There are no more excuses for continuing to send our tax dollars to other states and denying 300,000 working Missourians the opportunity to access affordable health care coverage through Medicaid expansion.” More…
FFM
No
MS
Bryant (R)
“Mississippi was right…not to willingly entrench Obamacare by establishing a state-based exchange, and I will continue to resist any efforts that attempt to shove Obamacare deeper into this state.” More…
SBM
No
MT
Bullock (D)
“Forty thousand Montanans can now be sure they will not lose their health insurance or have their taxes increased in order to maintain coverage.” More…
FFM
Yes1
NC
McCrory (R)
“[W]e must build a North Carolina-based reform plan that focuses on healthier patients at a cost taxpayers can afford. We must give doctors, hospitals and all health care providers the flexibility to provide their patients the highest quality care possible.” More…
FFM
No
ND
Dalrymple (R)
“This is what we anticipated when the Legislature decided to utilize the federal exchange. The Affordable Care Act is law and we expected it to be applied equally in all the states.” More…
FFM
Yes
NE
Ricketts (R)
“Today’s decision…allows Nebraskans to keep the health insurance premium subsidy provided under Obamacare. This decision maintains the status quo and does not appear to have any impact on the functionality of Obama’s healthcare law.” More…
FFM
No
NH
Hassan (D)
“We need to keep building on the new competition in our health insurance marketplace to continue making coverage more affordable and more accessible for all of our people and businesses. [I]t’s crucial that we also maintain our commitment…and eliminate the remaining uncertainty in the market by continuing our business-backed, bipartisan health care expansion plan.” More…
SPM
Yes1
NJ
Chrstie (R)
“State means state, not the federal government. This decision turns common language on its head. Now leaders must turn our attention to making the case that Obamacare must be replaced.” More…
FFM
Yes
NV
Sandoval (R)
“[W]e have remained confident that the thousands of Nevadans who rely on our Silver State Health Insurance Exchange would not be impacted…. We remain committed to state control of our marketplace and assuring affordable health plans are available to reduce the number of uninsured Nevadans.” More…
SBM
Yes
OH
Kasich (R)
“The law has driven up Ohio’s health insurance costs significantly and I remain convinced congress should repeal and replace it with something that actually reduces costs.” More…
FFM
Yes
OK
Fallin (R)
“The American people need Congress to use its powers to move the country towards constructive, market-oriented solutions that empower families, provide flexibility to states, improve health and reduce the cost of health care.” More…
FFM
No
PA
Wolf (D)
“I am extremely pleased with the Supreme Court’s ruling in King v. Burwell. As a result of this decision, roughly 382,000 Pennsylvanians will keep their much-needed assistance to help them afford health care.” More…
FFM
Yes1
RI
Raimondo (D)
“Last year, thousands of Rhode Islanders took advantage of almost $70 million in tax credits to gain the coverage they need to live healthy and productive lives. I applaud the Supreme Court for ensuring these benefits won’t be taken away from Americans across the country.” More…
SBM
Yes
SC
Haley (R)
“In South Carolina, we will continue to work around [the ACA] as best we can, finding better ways to make health care more affordable and give patients more choices.” More…
FFM
No
SD
Daugaard (R)
A spokeswoman for Gov. Dennis Daugaard, a Republican, said the state doesn’t have to change its approach to the federal health law since the court upheld the subsidies.
FFM
No
TN
Haslam (R)
“So while philosophically I did not agree with the ruling, in terms of the smoothness of the market and people being able to obtain insurance in a predictable way, it’s good.” More…
FFM
No
TX
Abbott (R)
“Today’s action underscores why it is now more important than ever to ensure we elect a President who will repeal Obamacare and enact real healthcare reforms.” More…
FFM
No
UT
Herbert (R)
“Ultimately, we are a nation of laws and I will continue to work diligently to maximize state flexibility within the legal parameters.” More…
FFM
No
VA
McAuliffe (D)
“This historic decision is a victory for the 286,000 Virginians who will now keep affordable health care that is essential to economic success. It is also a clear sign that now is the time to drop cynical efforts to prevent families from accessing care that will make their lives better.” More…
FFM
No
VT
Shumlin (D)
“This is very good news for the 6.4 million Americans who were in danger of losing their affordable health care coverage….We are making progress to deliver the services Vermonters expect through Vermont Health Connect. We have insured nearly 20,000 Vermonters who previously did not have insurance, and now Vermont has the second lowest rate of uninsured in the nation.” More…
SBM
Yes
WA
Inslee (D)
“I applaud the Supreme Court for upholding this landmark law that is helping so many people here in Washington state and across the nation. The Affordable Care Act has helped more than 730,000 Washingtonians find affordable care, and more than 300,000 of those had been uninsured.” More…
SBM
Yes
WI
Walker (R)
“Today’s ruling means Republicans must redouble their efforts to repeal and replace this destructive and costly law.” More…
FFM
No
WV
Tomblin (D)
Gov. Earl Ray Tomblin’s “appreciates” a U.S. Supreme Court ruling letting 28,000 West Virginians keep receiving federal subsidies for health insurance plans bought from a federal marketplace. More…
SPM
Yes
WY
Mead (R)
“Simply stated, this ruling maintains the status quo. It will still be necessary for Wyoming to develop its own path forward for better health care access and better health care for our citizens. I will continue to work with the Legislature on these important issues.” More…
https://www.wvva.com/story/29412364/206FFM
No
FFM = Federally-Facilitated Marketplace
SPM= State-Partnership Marketplace
SBM= State-Based Marketplace
1States have expanded Medicaid through an alternative expansion. For more details, please see this StateRefor(u)m chart.
Tax Reconciliation Cheat Sheet
The Affordable Care Act (ACA) makes health insurance coverage more affordable for many Americans by providing federal premium tax credits (PTC) to eligible individuals purchasing a qualified health plan (QHP) through a health insurance marketplace with individual income below $46,680 in 2014 (or households earning under 400% of the federal poverty line). To help make coverage more affordable for everyone purchasing coverage through marketplaces, the ACA requires that all Americans purchase health insurance coverage or pay a penalty (also known as a “shared responsibility payment”) unless it’s unaffordable or they are exempt. The 2014 tax season will be the first year these new requirements apply and need to be considered in the tax filing process. What this means practically speaking is new terminology, new forms, new requirements, and new questions from tax filers before April 15, 2015. State officials, legislators and consumer assisters will need to understand what these new requirements and forms mean and how to use them.
Between this chart, this blog, and these additional resources, we cover: what the new forms are; who needs to file what forms; what happens if they don’t file the forms; how some people may be able to get money back; who’s exempt; and where people can get more help.
Know of something we should add to this compilation? You can reach Corinne Alberts at calberts@oldsite.nashp.org.
Between this chart, this blog, and these additional resources, we cover: what the new forms are; who needs to file what forms; what happens if they don’t file the forms; how some people may be able to get money back; who’s exempt; and where people can get more help.
Know of something we should add to this compilation? You can reach Corinne Alberts at calberts@oldsite.nashp.org.
| Form/Resource Name | IRS Form Number | Form Information | Other Things to Know |
| Health Insurance Marketplace Statement | 1095-A | What is it? A new form issued by a marketplace to all consumers who purchased a QHP through a marketplace. Both Federally Facilitated Marketplaces (FFMs) and State-Based Marketplaces (SBMs) are required to issue Form 1095-A.
What is it used for? Form 1095-A includes all information needed to complete Form 8962, which is used to determine eligibility for Premium Tax Credits (PTC) and reconcile Advanced Premium Tax Credits (APTC) already received.
Who needs it? (1) Tax filers who purchased a QHP through a marketplace and received financial assistance; and (2) Tax-filers who purchased a QHP through a marketplace and did not receive financial assistance. |
(1) All QHP Purchasers Will Get One: All consumers who purchased a QHP through a marketplace will receive a Form 1095-A, whether or not they received financial assistance from the marketplace;
(2) QHP Households May Get More than One: Households may receive multiple 1095-A forms if: (a) A consumer or members of the consumer’s household are enrolled in more than one plan; (b) There are more than five (5) people on the 1095-A; (c) A consumer had a change in circumstance; or (d) A consumer changed her insurance plan. Complete instructions for Form 1095-A are available here. |
| Premium Tax Credit | 8962 | What is it? A new form that individuals must complete to calculate an individual’s Premium Tax Credit (PTC) and reconcile it with any Advanced Premium Tax Credit (APTC).
What is it used for? To demonstrate eligibility for a PTC and reconcile with any APTC received to determine whether funds are owed to or from the federal government at tax filing.
Who needs it? (1) Tax filers who purchased a QHP through a marketplace and received financial assistance; and (2) Tax-filers who purchased a QHP through a marketplace and did not receive financial assistance. |
(1) Need Form 1095-A To Complete It: In order to complete Form 8962, a tax filer must have a complete and accurate Form 1095-A; (2) Must Include All Tax Filers in the Household: Everyone in the tax filer’s household must be listed on Form 8962; (3) Additional Incentive to Complete this Form: All consumers enrolled in a QHP through the Exchange may want to complete Form 8962, even if the consumer did not receive APTC because APTC is advanced payment, and an individual may be eligible for a PTC, distributed in a lump sum when taxes are filed, and the only method of determining the PTC is by completing Form 8962. |
| Health Coverage Exemptions | 8965 | What is it? The Form that individuals must complete to apply for an exemption from the individual mandate. This is also the form used to calculate an individual’s tax penalty, known as the shared responsibility payment, if the taxpayer failed to obtain health insurance coverage and did not have an exemption.
What is it used for? To apply for an exemption from the tax penalty for failure to have health insurance coverage and to determine the tax penalty owed.
Who needs it? Tax filers who did not have health insurance coverage during the tax filing year for a period more than 3 months. |
Forms and Process Differ for ACA and Marketplace Exemptions: For ACA statutory exemptions claimed on a tax return, the tax-filer will need to file the tax return and complete Form 8965. For marketplace-granted coverage exemptions, the tax filer will need the Exemption Certificate Number (provided by a marketplace once the marketplace has processed an exemption application and approved it) in order to complete Form 8965. Complete instructions for Form 8965 are available here. |
| Health Care Law: What’s New for Individuals & Families | 5187 | What is it? A resource guide published by the IRS.
What is it used for? It provides information that explains how taxpayers satisfy the individual shared responsibility provision by enrolling in minimum essential coverage, qualifying for an exemption, or making a shared responsibility payment. It also provides information about the new premium tax credit.
Who needs it? Anyone who wants more information about new requirements under the ACA for individual and families. |
|
| CBPP: The Tax Preparer’s Guide to the Affordable Care Act | n/a | What is it? A resource guide for tax preparers published by the Center on Budget and Policy Priorities.
What is it used for? To educate tax preparers about new ACA requirements and help guide them through the tax filing process in light of the ACA.
Who needs it? Tax preparers |
Notes:
*Please note that individuals receiving Medicaid that meets minimum essential coverage (MEC) requirements are considered insured. If the Medicaid programs offered to an individual do not meet the MEC standards, the individual should qualify for an exemption.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
