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❆r❡ ❆❧❧ ▼❛♥❛❣❡❞ ❈❛r❡ P❧❛♥s ❈r❡❛t❡❞ ❊q✉❛❧❄ ❊✈✐❞❡♥❝❡ ❢r♦♠ ❘❛♥❞♦♠ P❧❛♥ ❆ss✐❣♥♠❡♥t ✐♥ ▼❡❞✐❝❛✐❞ ▼✐❝❤❛❡❧ ●❡r✉s♦ ✭❯❚ ❆✉st✐♥ ✫ ◆❇❊❘✮ ❚✐♠♦t❤② ▲❛②t♦♥ ✭❍❛r✈❛r❞ ✫ ◆❇❊❘✮ ❏❛❝♦❜ ❲❛❧❧❛❝❡ ✭❨❛❧❡✮ ❏✉♥❡ ✷✵✶✼ ❆❝❛❞❡♠②❍❡❛❧t❤✱ ❍❡❛❧t❤ ❊❝♦♥♦♠✐❝s ■♥t❡r❡st ●r♦✉♣✱ ✷✵✶✼ ●▲❲ ✭❱❛r✐♦✉s✮ ❙✉♣♣❧② ❙✐❞❡ ■♥❝❡♥t✐✈❡s ❏✉♥❡ ✷✵✶✼ ✶ ✴ ✹✸

■♥tr♦❞✉❝t✐♦♥ ▼♦t✐✈❛t✐♦♥ ❊①♣❡♥❞✐t✉r❡s t♦ Pr✐✈❛t❡ ▼▼❈ ♣❧❛♥s ❛❧s♦ ❣r♦✇✐♥❣ Figure 3: Federal Comprehensive Risk-Based Medicaid Managed Care Expenditures, Total and as a Percentage of Overall Federal Medicaid Expenditures, Fiscal Years 2004-2014 Note: For this analysis, expenditures were adjusted for inflation using the gross domestic product price index to 2014 dollars. ●▲❲ ✭❱❛r✐♦✉s✮ ❙✉♣♣❧② ❙✐❞❡ ■♥❝❡♥t✐✈❡s ❏✉♥❡ ✷✵✶✼ ✷ ✴ ✹✸ Federal expenditures for managed care varied widely by state—ranging

■♥tr♦❞✉❝t✐♦♥ ▼♦t✐✈❛t✐♦♥ ▼❡❞✐❝❛✐❞ ✐s ▲❛r❣❡st ■♥s✉r❡r✱ ▲❛r❣❡st ❯s❡r ♦❢ ▼❛♥❛❣❡❞ ❈❛r❡ Enrollment (millions) Expenditure (billions) 80.00 $600 70.00 $500 60.00 28.32 $400 50.00 $362 $314 40.00 $300 38.00 30.00 $200 43.39 20.00 $100 $162 $156 10.00 16.00 5.40 $22 0.00 $0 Marketplaces Medicare Medicaid Marketplaces Medicare Medicaid ●▲❲ ✭❱❛r✐♦✉s✮ ❙✉♣♣❧② ❙✐❞❡ ■♥❝❡♥t✐✈❡s ❏✉♥❡ ✷✵✶✼ ✸ ✴ ✹✸

❚❤✐s ✐s ❛♥ ✐♠♣♦rt❛♥t ♦♠✐ss✐♦♥✿ ❋♦r ♠❛♥② st❛t❡s t❤❡ r❡❧❡✈❛♥t q✉❡st✐♦♥ ✐s ♥♦t ✇❤❡t❤❡r t♦ ❞♦ ♠❛♥❛❣❡❞ ❝❛r❡ ❜✉t ❤♦✇ ■♥s✐❣❤ts ❢r♦♠ ♦t❤❡r ✐♥s✉r❛♥❝❡ ♠❛r❦❡ts ♠❛② ♥♦t ❝r♦ss ♦✈❡r t♦ ▼❡❞✐❝❛✐❞✿ ◆♦ ♣r❡♠✐✉♠s ❆✉t♦✲❛ss✐❣♥♠❡♥t ◆♦ ❝♦st✲s❤❛r✐♥❣ ❚❤r❡❛t ♦❢ ❡①❝❧✉s✐♦♥ ◆❡❡❞ ♠✉❝❤ ♠♦r❡ ✇♦r❦ ♦♥ t❤❡ ❡❝♦♥♦♠✐❝s ♦❢ t❤✐s ♣r♦❣r❛♠ ■♥tr♦❞✉❝t✐♦♥ ▼♦t✐✈❛t✐♦♥ ▲✐t❡r❛t✉r❡ ♦♥ ❡❝♦♥♦♠✐❝s ♦❢ ▼❡❞✐❝❛✐❞ ♠❛♥❛❣❡❞ ❝❛r❡ ❤❛s ♥♦t ❦❡♣t ✉♣ ✇✐t❤ ❣r♦✇t❤ ▼♦st ♦❢ t❤❡ ❧✐t❡r❛t✉r❡ ❢♦❝✉s❡s ♦♥ ❢❡❡✲❢♦r✲s❡r✈✐❝❡ ✈s✳ ♠❛♥❛❣❡❞ ❝❛r❡ ▲✐tt❧❡ ❢♦❝✉s ♦♥ ❤♦✇ t❤✐♥❣s ✇♦r❦ ✇✐t❤✐♥ ♠❛♥❛❣❡❞ ❝❛r❡ ❙♦♠❡ ❡①❝❡♣t✐♦♥s✿ ❱❛♥ P❛r②s ✭✷✵✶✺✮❀ ▼❛rt♦♥✱ ❡t ❛❧✳ ✭✷✵✶✹✮ ●▲❲ ✭❱❛r✐♦✉s✮ ❙✉♣♣❧② ❙✐❞❡ ■♥❝❡♥t✐✈❡s ❏✉♥❡ ✷✵✶✼ ✹ ✴ ✹✸

❚❤✐s ✐s ❛♥ ✐♠♣♦rt❛♥t ♦♠✐ss✐♦♥✿ ❋♦r ♠❛♥② st❛t❡s t❤❡ r❡❧❡✈❛♥t q✉❡st✐♦♥ ✐s ♥♦t ✇❤❡t❤❡r t♦ ❞♦ ♠❛♥❛❣❡❞ ❝❛r❡ ❜✉t ❤♦✇ ■♥s✐❣❤ts ❢r♦♠ ♦t❤❡r ✐♥s✉r❛♥❝❡ ♠❛r❦❡ts ♠❛② ♥♦t ❝r♦ss ♦✈❡r t♦ ▼❡❞✐❝❛✐❞✿ ◆♦ ♣r❡♠✐✉♠s ❆✉t♦✲❛ss✐❣♥♠❡♥t ◆♦ ❝♦st✲s❤❛r✐♥❣ ❚❤r❡❛t ♦❢ ❡①❝❧✉s✐♦♥ ◆❡❡❞ ♠✉❝❤ ♠♦r❡ ✇♦r❦ ♦♥ t❤❡ ❡❝♦♥♦♠✐❝s ♦❢ t❤✐s ♣r♦❣r❛♠ ■♥tr♦❞✉❝t✐♦♥ ▼♦t✐✈❛t✐♦♥ ▲✐t❡r❛t✉r❡ ♦♥ ❡❝♦♥♦♠✐❝s ♦❢ ▼❡❞✐❝❛✐❞ ♠❛♥❛❣❡❞ ❝❛r❡ ❤❛s ♥♦t ❦❡♣t ✉♣ ✇✐t❤ ❣r♦✇t❤ ▼♦st ♦❢ t❤❡ ❧✐t❡r❛t✉r❡ ❢♦❝✉s❡s ♦♥ ❢❡❡✲❢♦r✲s❡r✈✐❝❡ ✈s✳ ♠❛♥❛❣❡❞ ❝❛r❡ ▲✐tt❧❡ ❢♦❝✉s ♦♥ ❤♦✇ t❤✐♥❣s ✇♦r❦ ✇✐t❤✐♥ ♠❛♥❛❣❡❞ ❝❛r❡ ❙♦♠❡ ❡①❝❡♣t✐♦♥s✿ ❱❛♥ P❛r②s ✭✷✵✶✺✮❀ ▼❛rt♦♥✱ ❡t ❛❧✳ ✭✷✵✶✹✮ ●▲❲ ✭❱❛r✐♦✉s✮ ❙✉♣♣❧② ❙✐❞❡ ■♥❝❡♥t✐✈❡s ❏✉♥❡ ✷✵✶✼ ✹ ✴ ✹✸

■♥s✐❣❤ts ❢r♦♠ ♦t❤❡r ✐♥s✉r❛♥❝❡ ♠❛r❦❡ts ♠❛② ♥♦t ❝r♦ss ♦✈❡r t♦ ▼❡❞✐❝❛✐❞✿ ◆♦ ♣r❡♠✐✉♠s ❆✉t♦✲❛ss✐❣♥♠❡♥t ◆♦ ❝♦st✲s❤❛r✐♥❣ ❚❤r❡❛t ♦❢ ❡①❝❧✉s✐♦♥ ◆❡❡❞ ♠✉❝❤ ♠♦r❡ ✇♦r❦ ♦♥ t❤❡ ❡❝♦♥♦♠✐❝s ♦❢ t❤✐s ♣r♦❣r❛♠ ■♥tr♦❞✉❝t✐♦♥ ▼♦t✐✈❛t✐♦♥ ▲✐t❡r❛t✉r❡ ♦♥ ❡❝♦♥♦♠✐❝s ♦❢ ▼❡❞✐❝❛✐❞ ♠❛♥❛❣❡❞ ❝❛r❡ ❤❛s ♥♦t ❦❡♣t ✉♣ ✇✐t❤ ❣r♦✇t❤ ▼♦st ♦❢ t❤❡ ❧✐t❡r❛t✉r❡ ❢♦❝✉s❡s ♦♥ ❢❡❡✲❢♦r✲s❡r✈✐❝❡ ✈s✳ ♠❛♥❛❣❡❞ ❝❛r❡ ▲✐tt❧❡ ❢♦❝✉s ♦♥ ❤♦✇ t❤✐♥❣s ✇♦r❦ ✇✐t❤✐♥ ♠❛♥❛❣❡❞ ❝❛r❡ ❙♦♠❡ ❡①❝❡♣t✐♦♥s✿ ❱❛♥ P❛r②s ✭✷✵✶✺✮❀ ▼❛rt♦♥✱ ❡t ❛❧✳ ✭✷✵✶✹✮ ❚❤✐s ✐s ❛♥ ✐♠♣♦rt❛♥t ♦♠✐ss✐♦♥✿ ❋♦r ♠❛♥② st❛t❡s t❤❡ r❡❧❡✈❛♥t q✉❡st✐♦♥ ✐s ♥♦t ✇❤❡t❤❡r t♦ ❞♦ ♠❛♥❛❣❡❞ ❝❛r❡ ❜✉t ❤♦✇ ●▲❲ ✭❱❛r✐♦✉s✮ ❙✉♣♣❧② ❙✐❞❡ ■♥❝❡♥t✐✈❡s ❏✉♥❡ ✷✵✶✼ ✹ ✴ ✹✸

■♥tr♦❞✉❝t✐♦♥ ▼♦t✐✈❛t✐♦♥ ▲✐t❡r❛t✉r❡ ♦♥ ❡❝♦♥♦♠✐❝s ♦❢ ▼❡❞✐❝❛✐❞ ♠❛♥❛❣❡❞ ❝❛r❡ ❤❛s ♥♦t ❦❡♣t ✉♣ ✇✐t❤ ❣r♦✇t❤ ▼♦st ♦❢ t❤❡ ❧✐t❡r❛t✉r❡ ❢♦❝✉s❡s ♦♥ ❢❡❡✲❢♦r✲s❡r✈✐❝❡ ✈s✳ ♠❛♥❛❣❡❞ ❝❛r❡ ▲✐tt❧❡ ❢♦❝✉s ♦♥ ❤♦✇ t❤✐♥❣s ✇♦r❦ ✇✐t❤✐♥ ♠❛♥❛❣❡❞ ❝❛r❡ ❙♦♠❡ ❡①❝❡♣t✐♦♥s✿ ❱❛♥ P❛r②s ✭✷✵✶✺✮❀ ▼❛rt♦♥✱ ❡t ❛❧✳ ✭✷✵✶✹✮ ❚❤✐s ✐s ❛♥ ✐♠♣♦rt❛♥t ♦♠✐ss✐♦♥✿ ❋♦r ♠❛♥② st❛t❡s t❤❡ r❡❧❡✈❛♥t q✉❡st✐♦♥ ✐s ♥♦t ✇❤❡t❤❡r t♦ ❞♦ ♠❛♥❛❣❡❞ ❝❛r❡ ❜✉t ❤♦✇ ■♥s✐❣❤ts ❢r♦♠ ♦t❤❡r ✐♥s✉r❛♥❝❡ ♠❛r❦❡ts ♠❛② ♥♦t ❝r♦ss ♦✈❡r t♦ ▼❡❞✐❝❛✐❞✿ ◆♦ ♣r❡♠✐✉♠s ❆✉t♦✲❛ss✐❣♥♠❡♥t ◆♦ ❝♦st✲s❤❛r✐♥❣ ❚❤r❡❛t ♦❢ ❡①❝❧✉s✐♦♥ ◆❡❡❞ ♠✉❝❤ ♠♦r❡ ✇♦r❦ ♦♥ t❤❡ ❡❝♦♥♦♠✐❝s ♦❢ t❤✐s ♣r♦❣r❛♠ ●▲❲ ✭❱❛r✐♦✉s✮ ❙✉♣♣❧② ❙✐❞❡ ■♥❝❡♥t✐✈❡s ❏✉♥❡ ✷✵✶✼ ✹ ✴ ✹✸

❲❡ ❛s❦ ✶✳ ❉♦ ♣❧❛♥s ❞✐☛❡r ✐♥ s♣❡♥❞✐♥❣ ❛♥❞ q✉❛❧✐t② ✐♥ t❤✐s ❤✐❣❤❧② r❡❣✉❧❛t❡❞ s❡tt✐♥❣❄ ✷✳ ❍♦✇ ❞♦ t❤❡② ❛❝❤✐❡✈❡ t❤❡s❡ ❞✐☛❡r❡♥❝❡s❄ ✸✳ ❲❤❛t ❞♦ t❤❡s❡ ❞✐☛❡r❡♥❝❡s ❛♥❞ ❝♦♥s✉♠❡r ❝❤♦✐❝❡s t❡❛❝❤ ✉s ❛❜♦✉t t❤❡ ❡❝♦♥♦♠✐❝s ♦❢ t❤✐s ♠❛r❦❡t❄ ■♥tr♦❞✉❝t✐♦♥ ▼♦t✐✈❛t✐♦♥ ▼❡❞✐❝❛✐❞ ♠❛♥❛❣❡❞ ❝❛r❡ ✐♥ ◆❨❈ ■♥ t❤✐s ♣❛♣❡r✱ ✇❡ ❧❡✈❡r❛❣❡ r✐❝❤ ❛❞♠✐♥✐str❛t✐✈❡ ❞❛t❛ ❢r♦♠ ◆❡✇ ❨♦r❦ ❈✐t②✬s ▼❡❞✐❝❛✐❞ ♠❛♥❛❣❡❞ ❝❛r❡ ♣r♦❣r❛♠ t♦ ✐♠♣r♦✈❡ ♦✉r ✉♥❞❡rst❛♥❞✐♥❣ ♦❢ ▼▼❈ ❘♦❜✉st ▼❡❞✐❝❛✐❞ ♠❛♥❛❣❡❞ ❝❛r❡ ♠❛r❦❡t ▼✐❧❧✐♦♥s ♦❢ ❡♥r♦❧❧❡❡s ✭✷✴✸ ♦❢ st❛t❡ ▼❡❞✐❝❛✐❞ ♣♦♣✉❧❛t✐♦♥✮ ✶✵ ❤❡t❡r♦❣❡♥❡♦✉s ♠❛♥❛❣❡❞ ❝❛r❡ ♣❧❛♥s ❘❛♥❞♦♠ ❛ss✐❣♥♠❡♥t ♦❢ s✉❜s❡t ♦❢ ❡♥r♦❧❧❡❡s t♦ ♣❧❛♥s ●▲❲ ✭❱❛r✐♦✉s✮ ❙✉♣♣❧② ❙✐❞❡ ■♥❝❡♥t✐✈❡s ❏✉♥❡ ✷✵✶✼ ✺ ✴ ✹✸