SECTION 15. OTHER PROGRAMS

                                CONTENTS

Overview
Food Stamp Program
  Administration, Program Variations, and Funding
  Eligibility
  Benefits
  Quality Control (QC)
  Interaction with Cash Assistance Programs
  Recipiency Rates
  Legislative History
Medicaid
  Eligibility
  Categorically Needy
  Aged and Disabled Persons
  The Medically Needy
  Medicaid and the Poor
  Services
  Financing
  Reimbursement Policy
  Administration
  Medicaid and Managed Care
  Legislative History
  Program Data
Federal Housing Assistance
  Types of Assistance
  Trends in Commitments and Payments
School Lunch and Breakfast Programs
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Job Training Partnership Act
Head Start
Low-Income Home Energy Assistance Program (LIHEAP)
  Background
  Program Components
  Allotments to States
  Eligibility and Types of Assistance
  Planning and Administration
Veterans Benefits and Services
Workers' Compensation
  Overview Through 1993
  Recent Developments in Employers' Costs and Benefit Payments
References

                                OVERVIEW

    A wide variety of Federal programs outside the jurisdiction
of the Committee on Ways and Means provide benefits to
individuals and families that also receive assistance from
programs within the Committee's jurisdiction (see appendix K).
This section describes several such programs: food stamps;
Medicaid; housing assistance; School Lunch and Breakfast
Programs; the Special Supplemental Food Program for Women,
Infants, and Children (WIC); the Job Training Partnership Act;
Head Start; the Low-Income Home Energy Assistance Program
(LIHEAP); veterans benefits and services; and workers'
compensation.
    Most families receiving Aid to Families with Dependent
Children \1\ (AFDC) or Supplemental Security Income (SSI) would
have incomes low enough to qualify them--or particular members
of their families--for assistance under these programs. Unlike
the principal assistance programs under the jurisdiction of the
Committee on Ways and Means, participation in Head Start,
LIHEAP, and other programs is limited by appropriations. Income
received from AFDC is counted in determining eligibility and
benefit levels for these programs. However, because these
programs provide in-kind rather than cash assistance, benefits
are not counted in determining eligibility for AFDC.
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    \1\ AFDC was replaced by the Temporary Assistance for Needy
Families Program by Public Law 104-193 in 1996 (see section 7).
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    Tables 15-1 and 15-2 describe the overlap in recipients
between programs within the jurisdiction of the Committee on
Ways and Means and other major Federal assistance programs.
Table 15-1 illustrates that 87.2 percent of AFDC recipient
households also received food stamps during the first quarter
of 1995; 24.7 percent received WIC; 97.2 percent received
Medicaid; 63.1 percent received free or reduced-price school
meals; and 31.1 percent received housing assistance.
    Table 15-2 presents the percentage of recipients of other
means-tested programs who are participating in programs under
Ways and Means jurisdiction. For example, 48.9 percent of food
stamp households received AFDC benefits at some time during the
first quarter of 1995; 27.6 percent received SSI; 25.6 percent
received Social Security; 2.5 percent received unemployment
benefits; and 22.5 percent received Medicare.
    Table 15-3 shows the percentage of households receiving
AFDC or SSI and also receiving assistance from other programs
for selected time periods. The figures at the bottom of the
AFDC and SSI portions of the table show that the number of
households receiving AFDC increased rapidly between 1990 and
1994 and then declined somewhat in 1995. The AFDC rolls
increased by nearly one-third over the entire period. The
number of households receiving SSI declined slightly in 1990
and 1993, but otherwise increased throughout the period between
1984 and 1995. The rolls increased by more than 50 percent over
this period.

    TABLE 15-1.--PERCENT OF RECIPIENTS IN PROGRAMS WITHIN THE JURISDICTION OF THE COMMITTEE ON WAYS AND MEANS
                     RECEIVING ASSISTANCE FROM OTHER MAJOR FEDERAL ASSISTANCE PROGRAMS, 1995
----------------------------------------------------------------------------------------------------------------
                                                                      Ways and Means assistance program
                                                           -----------------------------------------------------
                 Other assistance program                                        Social   Unemployment
                                                              AFDC       SSI    Security  compensation  Medicare
----------------------------------------------------------------------------------------------------------------
Food stamps...............................................      87.2      50.0       7.7         9.1         7.4
WIC.......................................................      24.7       5.6       1.0         4.4         0.6
Medicaid..................................................      97.2     100.0      14.0        16.2        14.3
Free or reduced-price school meals........................      63.1      25.2       4.0        16.5         2.6
Public or subsidized rental housing.......................      31.1      24.1       6.8         4.1         7.2
VA compensation or pensions...............................       0.8       3.6       5.3         1.7         5.6
    Number of households receiving benefits (in thousands)     4,652     4,580    27,654       2,246     25,271
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Note.--Table shows number of households in the first quarter of 1995. Table reads that 87.2 percent of AFDC
  households also receive food stamps. SSI recipients living in California receive a higher SSI payment in lieu
  of food stamps, and thus are not included in the food stamp percentages.

 Source: U.S. Bureau of the Census.

    TABLE 15-2.--PERCENT OF RECIPIENTS IN OTHER MAJOR FEDERAL ASSISTANCE PROGRAMS RECEIVING ASSISTANCE UNDER
                    PROGRAMS WITHIN THE JURISDICTION OF THE COMMITTEE ON WAYS AND MEANS, 1995
----------------------------------------------------------------------------------------------------------------
                                                                      Other assistance program
                                                   -------------------------------------------------------------
                                                                    Free or   Public or
         Ways and Means assistance program           Food           reduced  subsidized                  VA
                                                    stamps    WIC    school    rental     Medicaid  compensation
                                                                     meals     housing               or pensions
----------------------------------------------------------------------------------------------------------------
AFDC..............................................    48.9    41.7     30.3      28.7         35.6        1.6
SSI...............................................    27.6     9.3     11.9      22.0         36.1        6.7
Social Security...................................    25.6     9.9     11.4      37.6         30.6       59.3
Unemployment compensation.........................     2.5     3.6      3.8       1.8          2.9        1.6
Medicare..........................................    22.5     5.8      6.8      36.2         28.4       57.7
    Number of households receiving benefits (in
     thousands)...................................   8,298   2,757    9,681     5,031       12,685     2,465
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Note.--Table shows households in the first quarter of 1995. Table reads that 48.9 percent of food stamp
  recipient households receive AFDC. SSI recipients living in California receive a higher SSI payment in lieu of
  food stamps, and thus are not included in the food stamp percentages.

 Source: U.S. Bureau of the Census.

    The percentage of AFDC and SSI households receiving other
benefits fluctuated somewhat over the period, but the general
trend was toward increased coverage for all benefits except VA
compensation or pensions. The percentage of AFDC households
receiving food stamps, for example, increased from 81 percent
in 1984 to 87 percent in 1995; receipt of Medicaid over the
same period increased from 93 to 97 percent of households.
Similarly, the percentage of SSI households receiving food
stamps increased from 46 to 50 percent while Medicaid coverage
held at or very near 100 percent over the period. The
percentage of AFDC and SSI households receiving WIC, school
meals, and housing also increased over the period 1984-95.

 TABLE 15-3.--PERCENT OF HOUSEHOLDS RECEIVING AFDC OR SSI AND ALSO RECEIVING ASSISTANCE FROM OTHER PROGRAMS FOR
                                              SELECTED TIME PERIODS
----------------------------------------------------------------------------------------------------------------
                                                                                   Year
                   Assistance program                    -------------------------------------------------------
                                                           1984    1987    1990    1992    1993    1994    1995
----------------------------------------------------------------------------------------------------------------
AFDC:
    Food stamps.........................................    81.4    81.7    82.7    86.2    88.9    88.3    87.2
    WIC.................................................    15.3    18.6    18.7    21.5    18.5    21.4    24.7
    Free or reduced-price school meals..................    49.2    55.6    52.7    55.5    56.9    57.5    63.1
    Public or subsidized rental housing.................    23.0    19.4    34.7    29.5    33.1    30.3    31.1
    Medicaid............................................    93.2    95.5    97.6    96.2    97.6    96.4    97.2
    VA compensation or pensions.........................     2.8     1.9     1.3     1.9     1.1     1.1     0.8
        Number of households receiving benefits (in
         thousands).....................................   3,585   3,527   3,434   4,057   4,831   4,906   4,652
SSI:
    Food stamps.........................................    46.5    39.7    41.3    46.2    48.0    50.1    50.0
    WIC.................................................     2.5     2.5     3.0     4.3     3.7     5.4     5.6
    Free or reduced-price school meals..................    12.7    11.9    15.3    18.2    21.3    23.8    25.2
    Public or subsidized rental housing.................    21.6    20.0    21.4    23.8    23.9    24.9    24.1
    Medicaid............................................   100.0    99.6    99.7    99.8    99.5   100.0   100.0
    VA compensation or pensions.........................     4.7     7.7     5.7     4.0     4.5     3.9     3.6
        Number of households receiving benefits (in
         thousands).....................................   3,008   3,341   3,037   3,957   3,861   4,223  4,580
----------------------------------------------------------------------------------------------------------------
Note.--SSI recipients living in California receive a higher SSI payment in lieu of food stamps, and thus are not
  included in the food stamp percentages.

 Source: U.S. Bureau of the Census.

                           FOOD STAMP PROGRAM

     Food stamps are designed primarily to increase the food
purchasing power of eligible low-income households to a point
where they can buy a nutritionally adequate low-cost diet.
Participating households are expected to be able to devote 30
percent of their counted monthly cash income to food
purchases.\2\ Food stamp benefits then make up the difference
between the household's expected contribution to its food costs
and an amount judged to be sufficient to buy an adequate low-
cost diet. This amount, the maximum food stamp benefit, is set
at the level of the U.S. Department of Agriculture's lowest
cost food plan (the Thrifty Food Plan), varied by household
size, and adjusted annually for inflation. Thus, a
participating household with no counted cash income receives
the maximum monthly allotment for its household size while a
household with some counted income receives a lesser allotment,
normally reduced from the maximum at the rate of 30 cents for
each dollar of counted income.
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    \2\ Because not all of a household's income is actually counted
when determining its food stamp benefits, the program, in effect,
assumes that most participants are able to spend about 20-25 percent of
their total cash monthly income on food.
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     Benefits are available to most households that meet
Federal eligibility tests for limited monthly income and liquid
assets. But household members must fulfill requirements related
to work effort and, in general, must be U.S. citizens.
Recipients in the two primary cash welfare programs (TANF and
SSI) generally are automatically eligible for food stamps, as
are recipients of State general assistance payments, if the
household is composed entirely of TANF, SSI, or general
assistance beneficiaries.\3\
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    \3\ Except for (1) SSI recipients in California, where a State-
financed adjustment to SSI benefits has replaced food stamp assistance;
and (2) general assistance programs that do not meet minimum Federal
standards.
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             Administration, Program Variations, and Funding

     The regular Food Stamp Program operates in all 50 States,
the District of Columbia, Guam, and the Virgin Islands. The
Federal Government is responsible for most of the rules that
govern the program, and, with limited variations for Alaska,
Hawaii, and the territories, these rules are nationally
uniform. However, major 1996 revisions to the Food Stamp Act
grant States a number of significant options to vary from
Federal administrative and benefit calculation rules,
especially for those who also are recipients of their State's
cash welfare programs, and a number of waivers from regular
rules and procedures have been (and continue to be) granted.
Sales taxes on food stamp purchases may not be charged, and
food stamp benefits do not affect other assistance available to
low-income households, nor are they taxed as income.
     Alternative programs are offered in Puerto Rico, the
Northern Mariana Islands, and American Samoa, and program
variations occur in a number of demonstration projects and in
those jurisdictions that have elected to exercise the limited
number of program options allowed.
     Funding is overwhelmingly Federal, although the States and
other jurisdictions have financial responsibility for
significant administrative costs, as well as liability for
erroneous benefit determinations (as assessed under the food
stamp ``quality control'' system, discussed later).
 Federal administrative responsibilities
     At the Federal level, the program is administered by the
Agriculture Department's Food and Consumer Service (FCS). The
FCS gives direction to welfare agencies through Federal
regulations that define eligibility requirements, benefit
levels, and administrative rules. It is also responsible for
arranging for printing food stamp coupons and distributing them
to welfare agencies, for overseeing State programs for the
electronic issuance of food stamp benefits, and for approving
and overseeing participation by retail food stores and other
outlets that may accept food stamps. Other Federal agencies
that have administrative roles to play include: the Federal
Reserve System (through which food stamp benefits are redeemed
for cash, and which has some jurisdiction over ``electronic
benefit transfer'' methods for issuing food stamp benefits),
the Social Security Administration (responsible for providing
the Social Security numbers recipients must have, for providing
limited application ``intake'' services, and for providing
information to verify recipients' income), the Internal Revenue
Service (providing assistance in verifying recipients' income
and assets), the Immigration and Naturalization Service
(helping welfare offices confirm alien applicants' status), and
the Secret Service and the Agriculture Department's Inspector
General (responsible for counterfeiting and trafficking
investigations).
State and local administrative responsibilities
     States, the District of Columbia, Guam, and the Virgin
Islands, through their local welfare offices, have primary
responsibility for the day-to-day administration of the Food
Stamp Program. They determine eligibility, calculate benefits,
and issue food stamp allotments (using coupons or electronic
benefit transfers) following Federal rules. They also have a
significant voice in carrying out employment and training
programs and in determining some administrative features of the
program (e.g., the extent to which verification of household
circumstances is pursued, the length of eligibility
certification periods, the structure of electronic benefit
transfer systems). Most often, the Food Stamp Program is
operated through the same welfare agency and staff that runs
the Federal/State TANF and Medicaid Programs.
 Puerto Rico, the Northern Mariana Islands, and American Samoa
     In addition to the regular Food Stamp Program, the Food
Stamp Act directs funding for a Nutrition Assistance Program in
the Commonwealth of Puerto Rico and another in American Samoa.
Separate legislation authorizes a variant of the Food Stamp
Program in the Commonwealth of the Northern Mariana Islands.
     Since July 1982, Puerto Rico has operated a Nutrition
Assistance Program of its own design, funded by an annual
Federal ``block grant.'' \4\ The Commonwealth's Nutrition
Assistance Program differs from the regular Food Stamp Program
primarily in that: (1) funding is limited to an annual amount
specified by law \5\; (2) the Food Stamp Act allows the
Commonwealth a great deal of flexibility in program design, as
opposed to the regular program's extensive Federal rules (e.g.,
benefits are paid in cash (checks) rather than food stamp
coupons); (3) income and liquid assets eligibility limits are
about half those used in the regular Food Stamp Program; (4)
maximum benefit levels are about one-quarter less than in the
48 contiguous States and the District of Columbia; and (5)
different rules are used in counting income for eligibility and
benefit purposes. In fiscal year 1996, Puerto Rico's Nutrition
Assistance Program aided approximately 1.3 million persons each
month with monthly benefits averaging $67 a person ($186 a
household).
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    \4\ Prior to July 1982, the regular Food Stamp Program operated in
Puerto Rico, although with slightly different eligibility and benefit
rules.
    \5\ For fiscal years 1997 and 1998, $1.174 billion and $1.204
billion are earmarked. The block grant funds the full cost of benefits
and half the cost of administration.
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     Under the terms of the 1976 Covenant with the Commonwealth
of the Northern Mariana Islands and implementing legislation
(Public Law 96-597), a variant of the Food Stamp Program was
negotiated with the Commonwealth and began operations in July
1982. The program in the Northern Marianas differs primarily in
that: (1) it is funded entirely by Federal money, up to a
maximum grant of $5.1 million a year; (2) a portion of each
household's food stamp benefit must be used to purchase locally
produced food; (3) maximum allotments are about 20 percent
higher than in the 48 contiguous States and the District of
Columbia; and (4) income eligibility limits are about half
those in the regular program. As of the end of fiscal year
1996, the Northern Marianas' program assisted almost 4,000
people each month with monthly benefits averaging $75 a person
(also see chapter 12).
     As with the Northern Marianas, American Samoa operates a
variant of the regular Food Stamp Program. Under the Secretary
of Agriculture's authority to extend Agriculture Department
programs to American Samoa (Public Law 96-597) and a 1996
amendment to the Food Stamp Act made by the Federal Agriculture
Improvement and Reform Act (Public Law 104-127), American Samoa
receives an annual grant of up to $5.3 million to operate a
Food Stamp Program limited to low-income elderly and disabled
persons. As of the end of fiscal year 1996, the program aided
about 3,000 persons a month with average monthly benefits of
just over $100 a person (also see chapter 12).
Program options
     The Food Stamp Act authorizes demonstration projects to
test program variations that might improve operations. At
present, three major types of demonstration projects are
underway: (1) a limited number of projects that ``cash out''
food stamp benefits (these projects cash out food stamps for
the elderly and SSI recipients, very poor households that are
eligible for expedited service, and some households that are
part of State welfare reform efforts); (2) welfare reform
demonstrations in which food stamp rules are changed to support
TANF reform efforts (e.g., food stamps are used as a wage
supplement or cashed out; food stamps are consolidated with
TANF benefits; food stamp income and asset rules are changed to
encourage employment); and (3) a project granting quarterly
(instead of monthly) benefit payments to SSI recipients
eligible for very small benefits.
     In addition to demonstration projects, States are allowed
to implement some optional aspects of the Food Stamp Program.
States may require ``monthly reporting'' and ``retrospective
budgeting'' for parts of their food stamp caseload. They may
issue benefits (at their own cost) to ineligible noncitizens
and those ineligible under the new work rule for able-bodied
adults without children (discussed later). With 50-percent
Federal cost sharing, they can operate ``outreach'' programs to
inform low-income persons about food stamps and support
nutrition education efforts. They may choose to issue food
stamp benefits through electronic benefit transfer systems.
They may choose to operate a ``simplified'' program under which
they can use many of their TANF rules and procedures when
determining food stamp benefits for TANF recipients. They
largely determine the length of eligibility certification
periods. They may sanction food stamp recipients failing to
meet other public asssistance program rules or failing to
cooperate in child support enforcement. They may, to a certain
extent, waive the application of the new work rule for able-
bodied adults without dependents (discussed later); and they
may choose to disqualify an entire household if the head of
household fails to fulfill work-related requirements. They may
include the cash value of food stamp benefits when using
welfare to subsidize some recipients' wages and can pay food
stamp benefits in cash to other working households getting off
cash welfare. Finally, States and localities may opt to run
``workfare'' programs, and States determine the type(s) of
employment or training programs in which recipients must
participate.
Funding
     The Food Stamp Act provides 100 percent Federal funding of
food stamp benefits, except where States choose to ``buy into''
the program and pay for issuing food stamp benefits to
ineligible noncitizens or those made ineligible by the new work
rule for able-bodied adults without dependents (discussed
later). The Federal Government also is responsible for its own
administrative costs: overseeing program operations (including
oversight of participating food establishments), printing and
distributing food stamp coupons to welfare agencies, redeeming
food stamp benefits through the Federal Reserve, and paying the
Social Security Administration for certain intake services.
     In most instances, the Federal Government provides half
the cost of State welfare agency administration.\6\ However,
the 50-percent Federal share can be increased to as much as 60
percent if the State has a very low rate of erroneous benefit
determinations. In addition, the Federal Government shares the
cost of carrying out employment and training programs for food
stamp recipients: (1) each State receives a Federal grant for
basic operating costs (a formula share of $79 million in fiscal
year 1997, rising to $212 in fiscal year 1998, and slightly
larger amounts in later years); and (2) additional operating
costs, as well as expenses for support services to participants
(e.g., transportation, child care) are eligible for a 50-
percent Federal match.\7\ Finally, States are allowed to retain
a portion of improperly issued benefits they recover (other
than those caused by welfare agency error): 35 percent of
recoveries in fraud cases and 20 percent in other
circumstances. The growth in Federal and State Food Stamp Act
spending since 1979 is shown in table 15-4.
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    \6\ Until April 1994, the cost of certain activities was matched at
more than the 50-percent rate: costs associated with the development of
computer capability and fraud control activities were eligible for 63
and 75 percent Federal sharing, respectively; costs for implementing
the Systematic Alien Verification for Entitlements (SAVE) Program were
fully reimbursed by the Federal Government.
    \7\ The overwhelming majority (80 percent) of the formula grant
funds must be spent on services to those covered by a new work
requirement for able-bodied adults without dependents (see later
discussion of work requirements).

             TABLE 15-4.--RECENT FOOD STAMP ACT EXPENDITURES
                        [In millions of dollars]
------------------------------------------------------------------------
                                             Administration \2\
                                            --------------------
         Fiscal year           Benefits \1\              State    Total
                                 (Federal)    Federal     and
                                                         local
------------------------------------------------------------------------
1979.........................       $6,480       $515      $388   $7,383
1980.........................        8,685        503       375    9,563
1981.........................       10,630        678       504   11,812
1982.........................       10,408        709       557   11,674
1983.........................       11,955        778       612   13,345
1984.........................       11,499        971       805   13,275
1985.........................       11,556      1,043       871   13,470
1986.........................       11,415      1,113       935   13,463
1987.........................       11,344      1,195       996   13,535
1988.........................       11,999      1,290     1,080   14,369
1989.........................       12,483      1,332     1,101   14,916
1990.........................       15,090      1,422     1,174   17,686
1991.........................       18,249      1,516     1,247   21,012
1992.........................       21,883      1,656     1,375   24,914
1993.........................       23,033      1,716     1,572   26,321
1994.........................       23,736      1,789     1,643   27,168
1995.........................       23,759      1,917     1,748   27,424
1996.........................       23,510      1,984     1,842  27,336
------------------------------------------------------------------------
\1\ All benefit costs associated with the Food Stamp Program and Puerto
  Rico's block grant are included. The benefit amounts shown in the
  table reflect small downward adjustments for overpayments collected
  from recipients and, beginning in 1989, issued but unredeemed
  benefits. Over time, the figures reflect both changes in benefit
  levels and numbers of recipients.
\2\ All Federal administrative costs associated with the Food Stamp
  Program and Puerto Rico's block grant are included: Federal matching
  for the various administrative and employment and training expenses of
  States and other jurisdictions, and direct Federal administrative
  costs. Figures for Federal administrative costs beginning with fiscal
  year 1989 include only those paid out of food stamp appropriation and
  the food stamp portion of the general appropriation for food program
  administration. Figures for earlier years include estimates of food
  stamp related Federal administrative expenses paid out of other
  Agriculture Department accounts. State and local costs are estimated
  based on the known Federal shares and represent an estimate of all
  administrative expenses of participating States and other
  jurisdictions (including Puerto Rico).

 Source: U.S Department of Agriculture budget justification materials
  for fiscal years 1981-98. Compiled by the Congressional Research
  Service.

                               Eligibility

     The Food Stamp Program has financial, employment/training-
related, and ``categorical'' tests for eligibility. Its
financial tests require that most of those eligible have
monthly income and liquid assets below limits set by food stamp
law. Under the employment/training-related tests, certain
household members must register for work, accept suitable job
offers, and fulfill work or training requirements (such as
looking or training for a job) established by State welfare
agencies. And, under a new work requirement established in 1996
law, food stamp eligibility for able-bodied adults without
dependents is limited to 3-6 months in any 36-month period
unless they are working at least half time or in a work or
training activity. Categorical eligibility rules make some
automatically eligible for food stamps (many TANF, SSI, and
general assistance recipients), and categorically deny
eligibility to others (e.g., strikers and most noncitizens,
postsecondary students, and people living in institutional
settings). Applications cannot be denied because of the length
of a household's residence in a welfare agency's jurisdiction
or because the household has no fixed mailing address or does
not reside in a permanent dwelling.
 The food stamp household
     The basic food stamp beneficiary unit is the
``household.'' A food stamp household can be either a person
living alone or a group of individuals living together; there
is no requirement for cooking facilities. The food stamp
household is unrelated to recipient units in other welfare
programs (e.g., TANF families with dependent children, elderly
or disabled individuals or couples in the SSI Program).
     Generally speaking, individuals living together constitute
a single food stamp household if they customarily purchase food
and prepare meals in common. Members of the same household must
apply together, and their income, expenses, and assets normally
are aggregated in determining food stamp eligibility and
benefits. However, persons who live together can sometimes be
considered separate ``households'' for food stamp purposes,
related coresidents generally are required to apply together,
and special rules apply to those living in institutional
settings. Most often, persons living together receive larger
aggregate benefits if they are treated as more than one food
stamp household.
     Persons who live together, but purchase food and prepare
meals separately, may apply for food stamps separately, except
for: (1) spouses; (2) parents and their children (21 years or
younger), and (3) minors 18 years or younger (excluding foster
children, who may be treated separately) who live under the
parental control of a caretaker. In addition, persons 60 years
or older who live with others and cannot purchase food and
prepare meals separately because of a substantial disability
may apply separately from their coresidents as long as their
coresidents' income is below prescribed limits.
    Although those living in institutional settings generally
are barred from food stamps, individuals in certain types of
group living arrangements may be eligible and are automatically
treated as separate households, regardless of how food is
purchased and meals are prepared. These arrangements must be
approved by State or local agencies and include: residential
drug addict or alcoholic treatment programs, small group homes
for the disabled, shelters for battered women and children, and
shelters for the homeless.
    Thus, different food stamp households can live together,
food stamp recipients can reside with nonrecipients, and food
stamp households themselves may be ``mixed'' (include
recipients and nonrecipients of other welfare benefits).
Income eligibility
    Except for households composed entirely of TANF, SSI, or
general assistance recipients (who generally are automatically
eligible for food stamps), monthly cash income is the primary
food stamp eligibility determinant.\8\ In establishing
eligibility for households without an elderly or disabled
member,\9\ the Food Stamp Program uses both the household's
basic (or ``gross'') monthly income and its counted (or
``net'') monthly income. When judging eligibility for
households with elderly or disabled members, only the
household's counted monthly income is considered; in effect,
this procedure applies a more liberal income test to elderly
and disabled households.
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    \8\ Although they do not have to meet food stamp income and assets
tests, TANF, SSI, and general assistance households must still have
their income calculated under food stamp rules to determine their food
stamp benefits.
    \9\ In the Food Stamp Program, ``elderly'' persons are those 60
years or older. The ``disabled'' generally are beneficiaries of
governmental disability-based payments (e.g., Social Security or SSI
disability recipients, disabled veterans, certain disability retirement
annuitants, and recipients of disability-based Medicaid or general
assistance).
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     Basic (or gross) monthly income includes all of a
household's cash income except the following ``exclusions''
(disregards): (1) most payments made to third parties (rather
than directly to the household); (2) unanticipated, irregular,
or infrequent income, up to $30 a quarter; (3) loans (deferred
repayment student loans are treated as student aid, see below);
(4) income received for the care of someone outside the
household; (5) nonrecurring lump-sum payments such as income
tax refunds and retroactive lump-sum Social Security payments
(these are instead counted as liquid assets); (6) Federal
energy assistance; (7) expense reimbursements that are not a
``gain or benefit'' to the household; (8) income earned by
schoolchildren 17 or younger; (9) the cost of producing self-
employment income; (10) Federal postsecondary student aid
(e.g., Pell grants, student loans); (11) advance payments of
Federal earned income credits; (12) ``on-the-job'' training
earnings of dependent children under 19 in Job Training
Partnership Act (JTPA) Programs, as well as JTPA monthly
``allowances''; (13) income set aside by disabled SSI
recipients under an approved ``plan to achieve self-
sufficiency'' (PASS); and (14) payments required to be
disregarded by provisions of Federal law outside the Food Stamp
Act (e.g., various payments under laws relating to Indians,
payments under the Older Americans Act Employment Program for
the Elderly).
     Counted (or net) monthly income is computed by subtracting
certain ``deductions'' from a household's basic (or gross)
monthly income. This procedure is based on the recognition that
not all of a household's income is equally available for food
purchases. Thus, a standard portion of income, plus amounts
representing work expenses or excessively high nonfood living
expenses, are disregarded.
     For households without an elderly or disabled member,
counted monthly income equals their gross monthly income less
the following deductions:
  --A standard deduction set at $134 a month, regardless of
        household size; different standard deductions are used
        for Alaska ($229), Hawaii ($189), Guam ($269), and the
        Virgin Islands ($118).
  --Any amounts paid as legally obligated child support;
  --Twenty percent of any earned income, in recognition of
        taxes and work expenses;
  --Out-of-pocket dependent care expenses, when related to work
        or training, up to $175 a month per dependent, $200 a
        month for children under age 2;
  --Shelter expenses that exceed 50 percent of counted income
        after all other deductions, up to a periodically
        adjusted ceiling now standing at $250 a month.
        Different ceilings prevail in Alaska, Hawaii, Guam, and
        the Virgin Islands: $434, $357, $304, and $184,
        respectively.
     For households with an elderly or disabled member, counted
monthly income equals gross monthly income less the following
deductions:
  --The same standard, child support, earned income, and
        dependent care deductions noted above;
  --Any shelter expenses, to the extent they exceed 50 percent
        of counted income after all other deductions, with no
        limit; and
  --Any out-of-pocket medical expenses (other than those for
        special diets) that are incurred by an elderly or
        disabled household member, to the extent they exceed a
        ``threshold'' of $35 a month.
     Except for those households comprised entirely of TANF,
SSI, or general assistance recipients, in which case food stamp
eligibility generally is automatic, all households must have
net monthly income that does not exceed the Federal poverty
guidelines, as adjusted for inflation each October. Households
without an elderly or disabled member also must have gross
monthly income that does not exceed 130 percent of the
inflation-adjusted Federal poverty guidelines. Both these
income eligibility limits are uniform for the 48 contiguous
States, the District of Columbia, Guam, and the Virgin Islands;
somewhat higher limits (based on higher poverty guidelines) are
applied in Alaska and Hawaii. The net and gross eligibility
limits on income are summarized in table 15-5.
 Allowable assets
     Except for households automatically eligible for food
stamps because they are composed entirely of TANF, SSI, or
general assistance recipients, eligible households must have
counted or liquid assets that do not exceed federally
prescribed limits. Households without an elderly member cannot
have counted liquid assets above $2,000. Households with an
elderly member cannot have counted liquid assets above $3,000.

 TABLE 15-5.--COUNTED (NET) AND BASIC (GROSS) MONTHLY INCOME ELIGIBILITY
           LIMITS FOR THE FOOD STAMP PROGRAM, FISCAL YEAR 1998
------------------------------------------------------------------------
                                    48 States, the
                                      District of
          Household size             Columbia, and    Alaska     Hawaii
                                          the
                                      territories
------------------------------------------------------------------------
Counted (net) monthly income
 eligibility limits \1\:
    1 person......................            $658       $823       $756
    2 persons.....................             885      1,106      1,017
    3 persons.....................           1,111      1,390      1,278
    4 persons.....................           1,338      1,673      1,539
    5 persons.....................           1,565      1,956      1,800
    6 persons.....................           1,791      2,240      2,060
    7 persons.....................           2,018      2,523      2,321
    8 persons.....................           2,245      2,806      2,582
    Each additional person........            +227       +284       +261
Basic (gross) monthly income
 eligibility limits \2\:
    1 person......................             855      1,070        983
    2 persons.....................           1,150      1,438      1,322
    3 persons.....................           1,445      1,806      1,661
    4 persons.....................           1,739      2,175      2,000
    5 persons.....................           2,034      2,543      2,339
    6 persons.....................           2,329      2,911      2,678
    7 persons.....................           2,623      3,280      3,018
     8 persons....................           2,918      3,648      3,357
     Each additional person.......            +295       +369      +340
------------------------------------------------------------------------
\1\ Set at the applicable Federal poverty guidelines, updated for
  inflation through calendar 1996.
\2\ Set at 130 percent of the applicable Federal poverty guidelines,
  updated for inflation through calendar 1996.

 Source: U.S. Department of Agriculture, Food and Consumer Service.

    Counted liquid assets include cash on hand, checking and
savings accounts, savings certificates, stocks and bonds,
individual retirement accounts (IRAs) and ``Keogh'' plans (less
any early withdrawal penalties), and nonrecurring lump-sum
payments such as insurance settlements. Certain ``less liquid''
assets are also counted: a portion of the value of vehicles
(generally, the fair market value in excess of $4,650) and the
equity value of property not producing income consistent with
its value (e.g., recreational property).
     Counted assets do not include the value of the household's
residence (home and surrounding property), business assets,
personal property (household goods and personal effects), lump-
sum earned income tax credit payments, burial plots, the cash
value of life insurance policies and pension plans (other than
Keogh plans and IRAs), and certain other resources whose value
is not accessible to the household or are required to be
disregarded by other Federal laws.
Work-related requirements
     Unless exempt, most able-bodied adults must (to gain or
retain eligibility) (1) register for work (typically with the
welfare agency or a State employment service office), (2)
accept a suitable job if offered one, (3) fulfill any work, job
search, or training requirements established by administering
welfare agencies, (4) provide the administering welfare agency
with sufficient information to allow a determination with
respect to their job availability, and (5) not voluntarily quit
a job without good cause or reduce work effort below 30 hours a
week. If the household head fails to fulfill any of these
requirements, the entire household may, at State option, be
disqualified for up to 180 days. Individual disqualification
periods differ according to whether the violation is the first,
second, or third; minimum periods (which may be increased by
the State welfare agency) range from 1 to 6 months.
     Those who are exempt by law from these basic work
requirements include: persons physically or mentally unfit for
work, those under age 16 or over age 59, and individuals
between 16 and 18 if they are not head of household or are
attending school or a training program; persons working at
least 30 hours a week or earning the minimum wage equivalent;
persons caring for dependents who are disabled or under age 6,
and those caring for children between ages 6 and 12 if adequate
child care is not available (this second exemption is limited
to allowing these persons to refuse a job offer if care is not
available); individuals already subject to and complying with
another assistance program's work, training, or job search
requirements; otherwise eligible postsecondary students; and
residents of drug addiction and alcoholic treatment programs.
     Those not exempted by one of the above-listed rules must,
at least, register for work and accept suitable job offers.
However, their State welfare agency may require them to fulfill
some type of work, job search, or training obligation. Welfare
agencies must operate an employment and training program of
their own design for work registrants whom they designate.
Welfare agencies may require all work registrants to
participate in one or more components of their program, or
limit participation by further exempting additional categories
and individuals for whom participation is judged impracticable
or not cost effective. Program components can include any or
all of the following activities: supervised job search or
training for job search, workfare, work experience or training
programs, education programs to improve basic skills, or any
other employment or training activity approved by the
Agriculture Department. However, at least 80 percent of
unmatched Federal money provided for States' employment and
training programs must be spent on services to those covered by
the new work rule for able-bodied adults without dependents
(see below).
     In fiscal year 1996, there were some 5.5 million work
registrants, of whom 40 percent were exempted from employment
and training program participation requirements. Of the
remainder, about 1.5 million persons participated in some
employment activity and almost 600,000 received ``notices of
adverse action'' because they failed to meet participation
requirements. The overwhelming majority of those fulfilling an
employment activity requirement participated in work or job
search or job search training (as opposed to education or other
training).
     Recipients who take part in an employment or training
activity beyond work registration cannot be required to work
more than the minimum wage equivalent of their household's
benefit, and total hours of participation (including both work
and any other required activity) cannot exceed 120 hours a
month. Welfare agencies also must provide participants support
for costs directly related to participation (e.g.,
transportation and child care). Agencies may limit this support
to $25 per participant per month for all support costs other
than dependent care, and to local market rates for necessary
dependent care.
     In addition to the above-noted work-related requirements
(e.g., work registration, participation in an employment and
training program if called on, a ban on voluntarily quitting a
job), the 1996 welfare reform law (the Personal Responsibility
and Work Opportunity Reconciliation Act) added a new work
requirement for most able-bodied adults (between 18 and 50)
without dependents. They are ineligible for food stamps if,
during the prior 36 months, they received food stamps for 3
months while not working at least 20 hours a week or
participating in an approved work/training activity (including
workfare). Those disqualified under this rule are able to
reenter the Food Stamp Program if, during a 30-day period, they
work 80 hours or more or participate in a work/training
activity. If they then become unemployed or leave work/
training, they are eligible for an additional 3-month period on
food stamps without working at least 20 hours a week or
participating in a work/training activity. But they are allowed
only one of these added 3-month eligibility periods in any 36
months for a potential total of 6 months on food stamps in any
36 months without half-time work or enrollment in a work/
training program.
     At State request, this rule can be waived for areas with
very high unemployment (over 10 percent) or lack of available
jobs. Moreover, States may, on their own initiative, exempt up
to 15 percent of those covered under the new work rule.
 Categorical eligibility rules and other limitations
     Some rules deny food stamp eligibility for reasons other
than financial need or compliance with work-related
requirements. Most noncitizens are barred (other than refugees
and asylees for a limited period of time, veterans, and those
with a substantial history of work covered under the Social
Security system). Households with members on strike are denied
benefits unless eligible prior to the strike. With some
exceptions, postsecondary students (in school half time or
more) who are fit for work and between ages 18 and 50 are
ineligible. Persons living in institutional settings are denied
eligibility, except those in special SSI-approved small group
homes for the disabled, persons living in drug addiction or
alcohol treatment programs, and persons in shelters for
battered women and children or shelters for the homeless.
Boarders cannot receive food stamps unless they apply together
with the household in which they are boarding. Those who
transfer assets for the purpose of qualifying for food stamps
are barred. Persons who fail to provide Social Security numbers
or cooperate in providing information needed to verify
eligibility or benefit determinations are ineligible. Food
stamps are denied those who intentionally violate program
rules, for specific time periods ranging from 1 year (on a
first violation) to permanently (on a third violation or other
serious infraction); and States may impose food stamp
disqualification when an individual is disqualified from
another public assistance program. Automatic disqualification
is required for those applying in multiple jurisdictions,
fleeing arrest, or convicted of a drug-related felony. And
States may disqualify individuals not cooperating with child
support enforcement authorities or in arrears on their child
support obligations.

                                Benefits

     Food stamp benefits are a function of a household's size,
its net monthly income, and maximum monthly benefit levels (in
some cases, adjusted for geographic location). An eligible
household's net income is determined (i.e., deductions are
subtracted from gross income), its maximum benefit level is
established, and a benefit is calculated by subtracting its
expected contribution (30 percent of its counted net income)
from its maximum allotment. Thus, a 3-person household with
$400 in counted net income (after deductions) would receive a
monthly allotment of $201 (the maximum 3-person benefit in the
48 States, $321, less 30 percent of net income, $120).
     Allotments are not taxable and food stamp purchases may
not be charged sales taxes. Receipt of food stamps does not
affect eligibility for or benefits provided by other welfare
programs, although some programs use food stamp participation
as a ``trigger'' for eligibility and others take into account
the general availability of food stamps in deciding what level
of benefits to provide. In fiscal year 1996, monthly benefits
averaged $73 a person and about $183 a household.
Maximum monthly allotments
     Maximum monthly food stamp allotments are tied to the cost
of purchasing a nutritionally adequate low-cost diet, as
measured by the Agriculture Department's Thrifty Food Plan
(TFP). Maximum allotments are set at: the monthly cost of the
TFP for a four-person family consisting of a couple between
ages 20 and 50 and two school-age children, adjusted for family
size (using a formula reflecting economies of scale developed
by the Human Nutrition Information Service), and rounded down
to the nearest whole dollar. Allotments are adjusted for food
price inflation annually, each October, to reflect the cost of
the TFP in the immediately previous June.
     Maximum allotments are standard in the 48 contiguous
States and the District of Columbia; they are higher,
reflecting substantially different food costs, in Alaska,
Hawaii, Guam, and the Virgin Islands (table 15-6).
 Minimum and prorated benefits
     Eligible one- and two-person households are guaranteed a
minimum monthly food stamp allotment of $10. Minimum monthly
benefits for other household sizes vary from year to year,
depending on the relationship between changes in the income
eligibility limits and the adjustments to the cost of the TFP.
In a few cases, benefits can be reduced to zero before income
eligibility limits are exceeded. At present, minimum monthly
allotments for households of three or more persons range from
$2 to over $80.
     In addition, a household's calculated monthly allotment
can be prorated (reduced) for 1 month. On application, a
household's first month's benefit is reduced to reflect the
date of application. If a previously participating household
does not meet eligibility recertification requirements in a
timely fashion, but does become certified for eligibility
subsequently, benefits for the first month of its new
certification period normally are prorated to reflect the date
when recertification requirements were met.

                      TABLE 15-6.--MAXIMUM MONTHLY FOOD STAMP ALLOTMENTS, FISCAL YEAR 1998
----------------------------------------------------------------------------------------------------------------
                                                                    48
                                                                  States
                                                                  and the                                 Virgin
                         Household size                          District  Alaska \1\   Hawaii    Guam   Islands
                                                                    of
                                                                 Columbia
----------------------------------------------------------------------------------------------------------------
1 person.......................................................      $122       $154      $197     $180     $157
2 persons......................................................       224        283       361      331      288
3 persons......................................................       321        405       517      474      413
4 persons......................................................       408        514       657      602      525
5 persons......................................................       485        611       780      715      623
6 persons......................................................       582        733       936      858      748
7 persons......................................................       643        810     1,035      948      827
8 persons......................................................       735        926     1,183    1,083      945
 Each additional person........................................       +92       +116      +148     +135    +118
----------------------------------------------------------------------------------------------------------------
\1\ Maximum monthly allotments for designated urban areas of Alaska. Two separate higher allotment levels are
  applied in remote rural areas of Alaska. They are 28 and 55 percent higher than the urban allotments shown
  here.

 Source: U.S. Department of Agriculture.

 Application, processing, and issuing food stamps
     Food stamp benefits normally are issued monthly. The local
welfare agency must either deny eligibility or make food stamps
available within 30 days of initial application and must
provide food stamps without interruption if an eligible
household reapplies and fulfills recertification requirements
in a timely manner. Households in immediate need because of
little or no income and very limited cash assets, as well as
the homeless and those with extraordinarily high shelter
expenses, must be given expedited service (provision of
benefits within 7 days of initial application).
     Food stamp issuance is a welfare agency responsibility,
and issuance practices differ among welfare agencies. Most food
stamp coupons are issued by: (1) providing (usually mailing)
recipients an authorization-to-participate (ATP) card that is
then turned in at a local issuance point (e.g., a bank or post
office) when picking up their monthly allotment; or (2) mailing
food stamp coupon allotments directly to recipients. However,
in a growing number of States, electronic benefit transfer
(EBT) systems are used. EBT systems replace coupons with an
ATM-like card used to make food purchases at the point of sale
by deducting the purchase amount from the recipient's food
stamp benefit account. EBT issuance is used (either statewide
or in part of the State) in over a dozen States (reaching more
than 20 percent of food stamp recipients). All remaining States
are well along in the process of converting to EBT issuance.
 Using food stamps
     Food stamp benefits are usually issued in the form of
booklets of coupons. The smallest coupon denomination is $1; if
change of less than $1 is due on a food stamp purchase, it is
returned in cash. Typically, participating households use their
food stamps in approved grocery stores to buy food items for
home preparation and consumption; food stamp purchases are not
taxable. However, the actual list of approved uses for food
stamps is more extensive, and includes: (1) food for home
preparation and consumption, not including alcohol, tobacco, or
hot foods intended for immediate consumption; (2) seeds and
plants for use in gardens to produce food for personal
consumption; (3) in the case of the elderly and SSI recipients
and their spouses, meals prepared and served through approved
communal dining programs; (4) in the case of the elderly and
those who are disabled to an extent that they cannot prepare
all of their meals, home-delivered meals provided by programs
for the homebound; (5) meals prepared and served to residents
of drug addiction and alcoholic treatment programs, small group
homes for the disabled, shelters for battered women and
children, and shelters or other establishments serving the
homeless; and (6) where the household lives in certain remote
areas of Alaska, equipment for procuring food by hunting and
fishing (e.g., nets, hooks, fishing rods, and knives). As noted
earlier, food stamp benefits also can be used through EBT
cards. In this case, the card is swiped through an approved
retailer's point-of-sale device, automatically debiting the
recipient's food stamp account and crediting the retailer's
bank account; unlike coupon transactions, recipients receive no
cash change.

                          Quality Control (QC)

     Since the early 1970s, the Food Stamp Program, like other
welfare programs, has had a quality control system to monitor
the degree to which erroneous eligibility and benefit
determinations are made by State welfare agencies. The system
was established by regulation in the 1970s as an administrative
tool to enable welfare officials to identify problems and take
corrective actions. Today, by legislative directive, the QC
system also is used to calculate and impose fiscal sanctions on
States that have very high rates of erroneous benefit and
eligibility decisions.
    Under the quality control system, welfare agencies, with
Federal oversight, continuously sample their active food stamp
caseloads, as well as their decisions to deny or end benefits.
The agencies perform indepth investigations of the eligibility
and benefit status of the randomly chosen cases looking for
errors in applying Federal rules and otherwise erroneous
benefit and eligibility outcomes. Over 90,000 cases are
reviewed each year, and each State's sample is designed to
provide a statistically valid picture of erroneous decisions
and, in most instances, their dollar value in benefits. The
resulting error rate information is used by program managers to
chart needed changes in administrative practices, and by the
Federal Government to assess fiscal sanctions on States with
error rates above certain tolerance levels. This information
also is used to reward States with error rates below a separate
lower tolerance level, and to review welfare agency plans for
action to correct procedures to control errors. Both error rate
findings and any assessed sanctions are subject to appeal
through administrative law judges and the Federal courts.
Sanctions may be reduced or waived if the State shows good
cause or if it is determined that the sanction amounts should
be invested in improved State administration. Interest may be
charged on outstanding sanction liabilities if the
administrative appeals process takes more than 1 year.
    Quality control reviews generate annual estimates of the
proportion of cases in which administrators or recipients make
an ``error'' and the dollar value of those errors. Caseload and
dollar error rates are calculated for overpayments (including
incorrect payments to eligible and ineligible households) and
underpayments. The accuracy of welfare agency decisions denying
or terminating assistance also is measured, with an error rate
reflecting the proportion of denials and terminations that were
improper; no dollar value is calculated. The national weighted
average for the dollar value of overpayments was estimated at
6.9 percent in fiscal year 1996 (table 15-7). This was just
under the all-time low of 7 percent in 1991. Error rates for
underpayments have been relatively unchanged over time. In
fiscal year 1996, the national weighted average underpayment
dollar error rate was estimated at 2.3 percent. Finally, the
rate of denials and terminations found improper in the most
recent estimate (1994) was 3.8 percent.

  TABLE 15-7.--FOOD STAMP QUALITY CONTROL ERROR RATES, FISCAL YEAR 1996
             [Percent of benefits paid or not paid in error]
------------------------------------------------------------------------
                                  Overpayment  Underpayment    Combined
              State                error rate   error rate    error rate
------------------------------------------------------------------------
Alabama.........................         4.87          0.93         5.80
Alaska..........................         5.22          2.27         7.50
Arizona.........................         6.99          1.45         8.44
Arkansas........................         3.64          0.90         4.54
 California.....................         5.65          3.73         9.32
Colorado........................         6.04          1.70         7.74
 Connecticut....................         8.92          1.74        10.65
Delaware........................         6.90          1.79         8.68
District of Columbia............         4.72          2.05         6.77
Florida.........................         7.43          2.27         9.70
Georgia.........................         7.20          3.06        10.26
Guam............................         7.11          2.51         9.62
Hawaii..........................         2.46          1.53         3.99
 Idaho..........................         3.89          2.39         6.28
 Illinois.......................        10.24          2.19        12.43
 Indiana........................         7.07          2.61         9.68
 Iowa...........................         9.40          2.80        12.20
 Kansas.........................         5.60          1.89         7.49
Kentucky........................         3.70          1.63         5.33
 Louisiana......................         4.48          1.49         5.97
 Maine..........................         5.98          1.39         7.37
 Maryland.......................         8.83          2.43        11.26
Massachusetts...................         3.40          1.29         4.69
 Michigan.......................         9.56          1.67        11.23
 Minnesota......................         5.51          1.44         6.95
 Mississippi....................         8.21          1.80        10.01
 Missouri.......................         9.91          3.47        13.38
 Montana........................         5.85          2.88         8.73
Nebraska........................         6.76          3.78        10.54
 Nevada.........................         7.79          2.84        10.63
 New Hampshire..................         7.19          2.17         9.37
 New Jersey.....................         6.22          2.48         8.70
 New Mexico.....................         5.94          2.02         7.96
New York........................         6.11          2.77         8.88
 North Carolina.................         7.73          2.27        10.00
 North Dakota...................         4.44          1.66         6.10
 Ohio...........................         9.31          3.32        12.63
 Oklahoma.......................         7.16          3.03        10.19
 Oregon.........................         9.03          2.14        11.17
Pennsylvania....................         6.99          2.22         9.21
Rhode Island....................         4.83          1.83         6.66
 South Carolina.................         4.32          2.00         6.32
 South Dakota...................         2.40          1.11         3.50
Tennessee.......................         7.14          1.84         8.99
Texas...........................         5.50          0.95         6.45
 Utah...........................         7.23          2.40         9.63
 Vermont........................         9.28          1.59        10.87
Virginia........................        10.92          3.03        13.95
 Virgin Islands.................         6.92          1.84         8.76
Washington......................         9.50          1.83        11.34
 West Virginia..................         9.05          3.35        12.40
 Wisconsin......................         9.27          2.13        11.40
 Wyoming........................         5.34          2.04         7.37
                                 ---------------------------------------
    U.S. average................         6.92          2.31        9.22
------------------------------------------------------------------------
Note.--Underpayment and overpayment rates may not add to combined rates
  due to rounding.

 Source: Food and Consumer Service (1997).

     The dollar error rates reported through the food stamp
quality control system are used as the basis for assessing the
financial liability of States for overpaid and underpaid
benefits. Although over $1 billion in sanctions have been
assessed since the early 1980s, less than $10 million has been
collected. The appeals process has delayed collection, and
sanctions have been forgiven or waived both by Congress and the
administration. In amending the rules governing sanctions in
1988 and 1990, Congress forgave accumulated sanctions, and, in
late 1992, the administration waived sanctions by allowing
States to invest the amounts in improved administration.
Permission for States to invest sanction amounts in improved
program administration has now become the rule, and States
regularly apply and agree to invest sanction amounts under
Federal guidelines rather than pay the Federal Government.
     Rules governing fiscal sanctions have changed a number of
times. Under the most recent revision (1993), sanctions are
assessed States with combined (overpayment and underpayment)
dollar error rates above the national weighted average combined
error rate for the year in question (9.2 percent in 1996). Each
State's sanction amount is determined by using a ``sliding
scale'' so that its penalty assessment equals an amount
reflecting the degree to which the State's combined error rate
exceeds the national average (the ``tolerance level''). For
example, if the tolerance level is 10 percent and a State's
error rate is 12 percent, the State would be assessed a
sanction of 0.4 percent of benefits paid in the State that year
(the State's error rate is 2 percentage points, or 20 percent,
above the tolerance level, and it is assessed a sanction
representing 20 percent of the amount by which it exceeds the
tolerance level; 2 percentage points  0.2 = 0.4). A
State with a combined error rate of 14 percent would owe a
penalty of 1.6 percent of benefits, or 40 percent of the amount
by which it exceeds the 10-percent tolerance level (4
percentage points  0.4 = 1.6). Thus, the degree to
which a State is assessed sanctions increases as its error rate
rises, rather than having sanctions assessed equally on each
dollar above the tolerance level. In fiscal year 1996, 24
States and Guam had combined error rates above the 9.2 percent
tolerance level and were assessed some $60 million.
     States also can receive increased Federal funding for
administration if their error rates are below a second, much
lower threshold. States with a combined error rate below 6
percent are entitled to a larger-than-normal Federal share of
their administrative costs. The regular 50-percent Federal
match is, depending on the degree to which the State's error
rate is below 6 percent, raised to a maximum of 60 percent, as
long as the State's rate of improper denials and terminations
is below the national average. This ``enhanced'' administrative
funding has typically totaled $10-$20 million a year; in fiscal
year 1996, six States had combined error rates below 6 percent
and received $15 million in enhanced funding.
    Finally, the quality control system identifies the various
sources of error and requires that States develop and carry out
corrective action plans to improve payment accuracy. These
reviews generally show that the primary responsibility for
overpayment errors is almost evenly split between welfare
agencies and clients. The most common errors are related to
establishing food stamp expense deductions and households'
income.
     Intentional program violations (e.g., fraud) can occur in
a number of ways; the most common are intentionally
misrepresenting household circumstances in order to obtain food
stamps or increase benefits and trafficking in food stamp
coupons. About one-quarter of the dollar value of erroneous
benefit and eligibility determinations identified through
quality control reviews are fraudulent--under 2 percent of all
benefits issued in 1996. The most recent Agriculture Department
study on the extent of food stamp coupon trafficking estimated
it at some $800 million in 1993--3.7 percent of all benefits
issued that year.

                Interaction With Cash Assistance Programs

     The Food Stamp Program is intertwined with cash assistance
in two ways: it is administratively linked to cash welfare aid
at the State and local levels, and its recipient population is
made up largely of recipients of other government benefits.
     At the State and local levels, the Food Stamp Program is
administered by the same welfare offices and personnel that
administer cash assistance such as TANF and general assistance.
Joint food stamp and cash welfare application and interview
procedures are the general rule. This coadministration does not
apply for most elderly or disabled persons, whose cash
assistance from the Supplemental Security Income Program (SSI)
is administered through Social Security Administration offices,
although these offices do provide limited intake services for
the Food Stamp Program.
    For most persons participating in the Food Stamp Program,
food stamp aid represents a second or third form of government
payment. Fewer than 20 percent of food stamp households rely
solely on nongovernmental sources for their cash income,
although over 25 percent have some income from these sources
(e.g., earnings, private retirement income). According to
quality control data, the AFDC Program (the predecessor to
TANF) contributed to the income of nearly 40 percent of food
stamp households, and for almost all of them AFDC is their only
cash income. SSI benefits go to some 23 percent of food stamp
households, and almost one-third of these have no other income.
About 20 percent of food stamp households receive Social
Security or veterans benefits; over 10 percent are paid general
assistance, unemployment insurance, or workers' compensation
benefits.

                            Recipiency Rates

     Table 15-8 shows food stamp participation rates from 1975
to 1996 using three different measures. Food stamp enrollment
has fluctuated widely over the last 20 years, reaching its peak
in fiscal year 1994; in that year, it averaged 27.5 million
persons a month, with an all-time high of 28 million in the
spring of 1994 (not including 1.4 million persons receiving aid
in Puerto Rico).
    A recent (October 1994) report from the U.S. Department of
Agriculture provides a more refined analysis of participation
rates and the extent to which the program is serving its target
population. The report estimates that 74 percent of persons
eligible participated (69 percent of eligible households).
These participants received 82 percent of benefits payable if
all eligibles had been enrolled. However, subgroups of the
food-stamp-eligible population participated at very diferent
rates: (1) most eligible children were enrolled (86 percent);
(2) only one-third of eligible elderly persons participated,
and the majority of those not participating lived alone; (3)
virtually all eligible single-parent households were enrolled,
while only 78 percent of eligible households with children and
two or more adults participated; (4) eligible households headed
by African-Americans participated at a greater rate (92
percent) than households headed by Hispanics (61 percent) or
white non-Hispanics (59 percent); and (5) virtually all
eligible households with income below half the Federal poverty
guidelines were enrolled, but the participation rate fell for
eligible households with larger incomes (e.g., the
participation rate for those with income between half the
poverty guidelines and the guidelines themselves was 76
percent). Finally, another (December 1995) report from the
Agriculture Department notes that about half of the major
increase in food stamp enrollment from 1988 to 1993 (a rise of
over 40 percent) was a result of a higher participation rate
among eligibles--as opposed to an increased number of eligible
persons.

                    TABLE 15-8.--FOOD STAMP PARTICIPATION RATES IN THE UNITED STATES, 1975-96
----------------------------------------------------------------------------------------------------------------
                                                                          Food stamp participation as a percent
                                                             Number of                     of--
                                                            food stamp  ----------------------------------------
                           Year                            participants                              Pretransfer
                                                                (in           Total         Poor         poor
                                                             millions)   population \1\  population   population
----------------------------------------------------------------------------------------------------------------
1975.....................................................         16.3            7.6          63.0           NA
1976.....................................................         17.0            7.9          68.1           NA
1977.....................................................         15.6            7.2          63.1           NA
1978.....................................................         14.4            6.5          58.8           NA
1979.....................................................         15.9            7.1          61.0         57.1
1980.....................................................         19.2            8.4          65.6         60.7
1981.....................................................         20.6            9.0          64.7         60.8
1982.....................................................         20.4            8.8          59.3         56.3
1983.....................................................         21.6            9.2          61.2         58.5
1984.....................................................         20.9            8.8          62.0         58.5
1985.....................................................         19.9            8.3          60.2         56.6
1986.....................................................         19.4            8.0          59.9         56.2
1987.....................................................         19.1            7.8          59.1         55.6
1988.....................................................         18.7            7.6          58.9         55.2
1989.....................................................         18.8            7.6          59.6         55.6
1990.....................................................         20.0            8.0          59.6         55.7
1991.....................................................         22.6            9.0          63.3         59.3
1992.....................................................         25.4           10.0          68.9         64.0
1993.....................................................         27.0           10.4          68.7           NA
1994.....................................................         27.5           10.5          72.1           NA
1995.....................................................         26.6           10.1          73.0           NA
1996.....................................................         25.5            9.6          69.8          NA
----------------------------------------------------------------------------------------------------------------
\1\ Calculated as a percent of total U.S. resident population at the end of the fiscal year. Total U.S. resident
  population was 266.22 million persons at the end of fiscal year 1996.

 NA--Not available.

 Note.--Participants in Puerto Rico are not included in this table.

 Source: U.S. Bureau of the Census.

     Table 15-9 shows the average monthly number of people (in
thousands) who received food stamp benefits in each State, the
District of Columbia, and the participating Commonwealths and
territories for selected years between 1975 (when the Food
Stamp Program became nationally available) and 1996. There has
been a general increase in food stamp participants since 1975,
with enrollment peaking in 1994. The number of recipients has
declined significantly since its height in the spring of 1994.

                           Legislative History

     In the early 1980s, Congress enacted major revisions to
the Food Stamp Program to hold down costs and tighten
administrative rules. The Omnibus Budget Reconciliation Act of
1981, the Agriculture and Food Act of 1981, and the Omnibus
Budget Reconciliation Act of 1982 all contained amendments that
the Congressional Budget Office has estimated held food stamp
spending for fiscal years 1982 through 1985 nearly $7 billion
(13 percent) below what would have been spent under pre-1981
law. These laws delayed various inflation indexing adjustments,
reduced the maximum benefit guarantee by 1 percent (restored in
1984), established income eligibility ceilings at 130 percent
of the Federal poverty levels, initiated prorating of first-
month benefits, replaced the Food Stamp Program in Puerto Rico
with a nutrition assistance block grant, reduced benefits for
those with earnings and high shelter expenses, ended
eligibility for most postsecondary students and strikers, and
raised fiscal penalties for States with high rates of erroneous
benefit and eligibility determinations.
     In 1985, the Food Security Act (Public Law 99-198)
reauthorized food stamp appropriations through fiscal year 1990
and reversed the earlier trend, significantly liberalizing food
stamp rules. Major new initiatives included: a requirement for
States to implement employment and training programs for food
stamp recipients, automatic food stamp eligibility for AFDC and
SSI recipients, and a prohibition on collection of sales taxes
on food stamp purchases. Benefits were raised for some disabled
and those with earnings, high shelter costs, and dependent care
costs. Puerto Rico's nutrition assistance block grant was
increased. Eligibility standards were liberalized, primarily by
increasing and easing limits on assets. This was followed by
several laws in 1986 and 1987 that opened up access to and
increased benefits for the homeless, liberalized treatment of
student aid, energy assistance, and income received from
employment programs for the elderly and charitable
organizations, further added to benefits for those with high
shelter costs, and allowed Washington State to operate a
special AFDC/food stamp demonstration project (followed by
similar authorization for Minnesota in 1989).

                                       TABLE 15-9.--FOOD STAMP RECIPIENTS BY STATE, SELECTED FISCAL YEARS 1975-96
                                                                 [Thousands of persons]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                        State                         1975 \1\  1979 \2\  1985 \3\  1990 \3\  1991 \3\  1992 \3\  1993 \3\  1994 \3\  1995 \3\  1996 \3\
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama.............................................       393       525       588       449       504       550       560       551       525       509
Alaska..............................................        12        25        22        25        30        38        43        46        45        46
Arizona.............................................       166       129       206       317       388       457       489       512       480       427
Arkansas............................................       268       277       253       235       258       277       285       283       272       274
California..........................................     1,517     1,334     1,615     1,936     2,212     2,558     2,866     3,155     3,175     3,143
Colorado............................................       162       145       170       221       241       260       273       268       252       244
Connecticut.........................................       189       155       145       133       171       202       215       223       227       223
Delaware............................................        39        45        40        33        41        51        58        59        57        58
District of Columbia................................       112       100        72        62        72        82        87        91        94        93
Florida.............................................       767       828       630       781     1,021     1,404     1,500     1,474     1,395     1,371
Georgia.............................................       569       559       567       536       648       751       807       830       816       793
Hawaii..............................................        84        96        99        77        83        94       103       115       125       130
Idaho...............................................        39        47        59        59        65        72        79        82        80        80
Illinois............................................       948       837     1,110     1,013     1,096     1,156     1,178     1,189     1,151     1,105
Indiana.............................................       255       275       406       311       375       448       497       521       470       390
Iowa................................................       118       117       203       170       180       192       196       196       184       177
Kansas..............................................        63        73       119       142       156       175       188       192       184       172
Kentucky............................................       449       405       560       458       496       529       530       522       520       478
Louisiana...........................................       502       523       644       727       742       779       779       756       711       670
Maine...............................................       151       121       114        94       116       133       138       136       132       131
Maryland............................................       273       299       291       254       304       343       375       387       399       375
Massachusetts.......................................       560       429       337       347       397       429       443       442       410       374
Michigan............................................       685       706       985       917       978       994     1,022     1,031       971       935
Minnesota...........................................       191       143       228       263       286       309       317       316       308       295
Mississippi.........................................       390       452       495       499       520       536       537       511       480       457
Missouri............................................       299       280       362       431       490       549       591       593       576       554
Montana.............................................        38        33        58        57        61        66        70        71        71        71
Nebraska............................................        50        55        94        95        99       107       113       111       105       102
Nevada..............................................        34        27        32        50        63        80        93        97        99        97
New Hampshire.......................................        66        44        28        31        47        58        60        62        58        53
New Jersey..........................................       565       524       464       381       441       495       531       545       540       541
New Mexico..........................................       154       159       157       157       188       221       244       244       239       235
New York............................................     1,398     1,704     1,834     1,546     1,717     1,885     2,045     2,154     2,183     2,099
North Carolina......................................       537       517       474       419       517       597       627       630       614       631
North Dakota........................................        19        20        33        39        41        46        48        45        41        40
Ohio................................................       924       760     1,133     1,078     1,171     1,251     1,269     1,245     1,155     1,045
Oklahoma............................................       184       184       263       267       296       346       370       376       375       354
Oregon..............................................       208       160       228       216       240       265       283       286       289       288
Pennsylvania........................................       893       923     1,032       954     1,052     1,137     1,186     1,208     1,173     1,124
Rhode Island........................................       104        80        69        64        78        87        92        93       100        91
South Carolina......................................       421       369       373       299       329       369       394       385       364       358
South Dakota........................................        31        37        48        50        52        55        56        53        50        49
Tennessee...........................................       435       531       518       527       608       702       774       735       662       638
Texas...............................................     1,085     1,027     1,263     1,880     2,155     2,454     2,659     2,730     2,564     2,372
Utah................................................        50        44        75        99       110       123       133       128       119       110
Vermont.............................................        46        40        44        38        47        54        58        65        59        56
Virginia............................................       293       320       360       346       414       495       535       547       546       538
Washington..........................................       239       205       281       337       385       432       462       468       476       476
West Virginia.......................................       204       182       278       262       281       310       322       321       329       300
Wisconsin...........................................       163       171       363       286       294       334       337       330       320       283
Wyoming.............................................        11        11        27        28        31        33        34        34        34        33
American Samoa......................................        NA        NA        NA        NA        NA        NA        NA         2         3         3
Guam................................................        21        18        20        12        11        20        13        15        16        18
Northern Marianas...................................        NA        NA         4         4         2         2         3         4         4         4
Puerto Rico.........................................     1,800     1,822     1,480     1,480     1,490     1,480     1,440     1,410     1,370     1,330
Virgin Islands......................................        25        34        32        18        15        16        18        20        23        31
                                                     ---------------------------------------------------------------------------------------------------
      Total.........................................    19,199    18,926    21,385    21,510    24,105    26,888    28,426    28,888    27,995   26,871
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Year end participation, July 1975. Total does not match totals in other tables, which are annual average participation.
\2\ Year end participation, September 1979. Total does not match totals in other tables, which are annual average participation. During fiscal year
  1979, and into 1980, participation increases were largely due to the elimination of the food stamp purchase requirement. Figures for Alabama and
  Mississippi are estimates.
\3\ Annual average monthly participation.

 NA--Not available.

 Source: U.S. Department of Agriculture, Food and Consumer Service. Compiled by the Congressional Research Service.

     Legislation expanding eligibility and benefits continued
into 1988 and 1989. The Hunger Prevention Act of 1988 (Public
Law 100-435) increased food stamp benefits across the board,
liberalized several eligibility and benefit rules, eased
program access and administrative rules, and restructured the
employment and training program and quality control system. The
across-the-board benefit increase in maximum benefits (above
normal inflation adjustments) called for by the act was 0.65
percent in fiscal year 1989, 2.05 percent in fiscal year 1990,
and 3 percent in later years. Eligibility and benefit
liberalizations included higher benefits for those with
dependent care expenses, extension of liberal treatment for
disabled applicants and recipients to new categories of
disability, addition of a new income disregard for earned
income tax credits, and liberalized treatment for farm
households. Major provisions pertaining to program access and
administration authorized 50-percent Federal cost sharing for
State-option outreach activities, required coordination with
cash welfare program application procedures, loosened rules
governing monthly reporting and retrospective budgeting,
allowed training of community volunteers to help screen
applicants, and required, in some instances, issuance of the
first 2 months' worth of benefits in a single allotment.
Employment and training rules were revised by allowing some
expansion in the types of activities supported (e.g., basic
skills education), requiring increased support for
participants' dependent care expenses, and mandating new
performance standards for States. Finally, the food stamp
quality control system was completely revamped to substantially
reduce fiscal sanctions on States for erroneous benefit
determinations, retroactive to fiscal year 1986.
     The 1990 Food, Agriculture, Conservation, and Trade Act
(Public Law 101-624) reauthorized food stamp appropriations
through fiscal year 1995. Although early versions of this act
would have significantly liberalized food stamp eligibility and
benefit rules, budget constraints dictated minimal expansions.
The changes included: limited revisions for postsecondary
students, forgiveness of most pre-1986 quality control
sanctions on States, a few changes in administrative rules to
open up program access and strengthen penalties for
trafficking, and new pilot projects and study commissions for
welfare program coordination. In addition, other laws
eliminated a special requirement for single food stamp/SSI
applications for those about to be discharged from institutions
and barred the Food Stamp Program from counting (as a liquid
asset) lump-sum earned income tax credit payments.
    The Mickey Leland Childhood Hunger Relief Act (incorporated
in the 1993 Omnibus Budget Reconciliation Act, Public Law 103-
66) increased food stamp benefits and eased eligibility rules
by: increasing and then removing the limit on special benefit
adjustments (deductions) for households with very high shelter
expenses, ending a practice of reducing benefits when there are
short ``procedural'' breaks in enrollment, disregarding child
support payments as income to the payor, increasing the degree
to which vehicles are disregarded as assets in judging
eligibility, revising the definition of a food stamp household
to allow more persons who live together to apply separately,
increasing the degree to which dependent care expense
deductions can be claimed, expanding the degree to which earned
income credits are disregarded as assets and State/local
general assistance is disregarded as income, and boosting
Puerto Rico's block grant. The act also lowered the Federal
share of some State administrative expenses (to 50 percent),
reduced quality control fiscal penalties on States with high
rates of erroneous benefit and eligibility determinations, and
liberalized the appeals process for those penalties. Finally,
it expanded support for employment and training programs for
food stamp recipients, added a new method for collecting claims
against recipients, and increased penalties for trafficking in
food stamps. The net cost of the 1993 amendments was estimated
at $2.5 billion over fiscal years 1994-98.
     The 1996 Omnibus ``farm bill'' (the Federal Agriculture
Improvement and Reform Act; Public Law 104-127) extended the
Food Stamp Act's overall authorization for appropriations
through fiscal year 1997, with no specific dollar limits. It
also: (1) continued the requirement for nutrition assistance
grants to Puerto Rico and American Samoa, and for employment
and training programs, through fiscal year 2002; (2) revised
rules for penalizing food stores in trafficking cases involving
management; and (3) extended authority for several pilot
projects.
     Most recently table 15-10 provides an overview of the
characteristics of food stamp households for selected years
since 1980; table 15-11 summarizes annual vital statistics
about the program since 1972.

                                     TABLE 15-10.--CHARACTERISTICS OF FOOD STAMP HOUSEHOLDS, SELECTED YEARS 1980-95
                                                                      [In percent]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                  Year and month survey was conducted
                                             -----------------------------------------------------------------------------------------------------------
       Food stamp recipient households         1980     1985      1987      1988      1989      1990      1991      1992      1993      1994      1995
                                              (Aug.)  (Summer)  (Summer)  (Summer)  (Summer)  (Summer)  (Summer)  (Summer)  (Summer)  (Summer)  (Annual)
--------------------------------------------------------------------------------------------------------------------------------------------------------
With gross monthly income:
    Below the Federal poverty levels........      87       94        94        92        92        92        91        92        91        90        92
    Between the poverty levels and 130
     percent of the poverty levels..........      10        6         6         8         8         8         9         8         8         9         8
    Above 130 percent of the poverty levels.       2    (\3\)     (\3\)     (\3\)     (\3\)     (\3\)     (\3\)     (\3\)         1         1     (\3\)
With earnings...............................      19       20        21        20        20        19        20        21        21        21        21
With public assistance income \1\...........      65       68        74        72        73        73        70        66        68        69        68
    With AFDC income........................      NA       39        41        42        42        43        41        40        40        38        38
    With SSI income.........................      18       19        21        20        21        19        19        19        20        23        23
With children...............................      60       59        61        61        60        61        61        62        60        61        60
    And female heads of household...........      NA       46        50        50        50        51        51        51        52        51        50
With elderly members \2\....................      23       21        21        19        20        18        17        15        16        16        16
    With elderly female heads of household
     \2\....................................      NA       16        15        14        14        11        10         9        NA        11        NA
                                             -----------------------------------------------------------------------------------------------------------
Average household size......................     2.8      2.7       2.7       2.6       2.6       2.6       2.6       2.5       2.6       2.5      2.5
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Public assistance income includes Aid to Families with Dependent Children, Supplemental Security Income, and general assistance.
\2\ Elderly members and heads of household include those age 60 or older.
\3\ Percentage equals 0.5 or less.

 NA--Not available.

 Note.--The proportion of households with public assistance income shown in this table is an estimate that generally overcounts them because it is not
  corrected for households with multiple sources of public assistance income. The proportion of households with elderly female heads shown in this table
  for years prior to 1994 is an estimate that generally undercounts them because it counts only single-person female households. The 1995 figures
  represent characteristics over the full course of fiscal year 1995.

 Source: U.S. Department of Agriculture, Food and Consumer Service surveys of the characteristics of food stamp households. Compiled by the
  Congressional Research Service.

                             TABLE 15-11.--HISTORICAL FOOD STAMP STATISTICS, 1972-96
----------------------------------------------------------------------------------------------------------------
                                    Total Federal spending                     Average monthly
                                       (in millions) \1\       Average      benefits (per person)   Four-person
                                   ------------------------    monthly    ------------------------    maximum
            Fiscal year                          Constant   participation               Constant      monthly
                                     Current      (1996)     (in millions   Current      (1996)    allotment \2\
                                     dollars   dollars \3\   of persons)    dollars   dollars \3\
----------------------------------------------------------------------------------------------------------------
1972 \4\..........................     $1,871      $7,072          11.1       $13.50      $49.30          $108
1973..............................      2,211       8,048          12.2        14.60       49.20           112
1974..............................      2,843       9,496          12.9        17.60       49.60           116
1975 \5\..........................      4,624      13,872          17.1        21.40       55.00           150
1976..............................      5,692      15,995          18.5        23.90       57.80           162
Transition quarter \6\............      1,367       3,705          17.3        24.40       58.60           166
1977..............................      5,469      14,274          17.1        24.70       57.30           166
1978..............................      5,573      13,598          16.0        26.80       56.80           170
1979 \7\..........................      6,995      15,459          17.7        30.60       58.10           182
1980..............................      9,188      17,917          21.1        34.40       60.90           204
1981..............................     11,308      19,789          22.4        39.50       64.00           209
1982 \8\..........................     11,117      18,121          22.0        39.20       61.20           233
1983 \8\..........................     12,733      20,118          23.2        43.00       66.20           253
1984 \8\..........................     12,470      18,830          22.4        42.70       64.10           253
1985 \8\..........................     12,599      18,395          21.4        45.00       66.20           264
1986 \8\..........................     12,528      17,790          20.9        45.50       65.50           268
1987 \8\..........................     12,539      17,304          20.6        45.80       62.70           271
1988 \8\..........................     13,289      17,674          20.1        49.80       66.20           290
1989 \8\..........................     13,815      17,545          20.2        51.90       64.40           300
1990 \8\..........................     16,512      19,980          21.5        59.00       69.00           331
1991 \8\..........................     19,765      22,730          24.1        63.90       71.60           352
1992 \8\..........................     23,539      26,364          26.9        68.50       76.70           370
1993 \8\..........................     24,749      26,729          28.4        68.00       74.80           375
1994..............................     25,525      27,057          28.9        69.00       73.80           375
1995..............................     25,676      26,446          28.0        71.30       73.40           386
1996..............................     25,494      25,494          26.9        73.30       73.30          397
----------------------------------------------------------------------------------------------------------------
\1\ Spending for benefits and administration, including Puerto Rico.
\2\ For the 48 contiguous States and the District of Columbia, as in effect at the beginning of the fiscal year
  in current dollars.
\3\ Constant dollar adjustments were made using the overall Consumer Price Index for Urban Consumers (CPI-U) for
  spending and the CPI-U ``food at home'' component for benefits.
\4\ The first fiscal year in which benefit and eligibility rules were, by law, nationally uniform and indexed
  for inflation.
\5\ The first fiscal year in which food stamps were available nationwide.
\6\ July through September 1976.
\7\ The fiscal year in which the food stamp purchase requirement was eliminated, on a phased in basis.
\8\ Includes funding for Puerto Rico's nutrition assistance grant; earlier years include funding for Puerto Rico
  under the regular Food Stamp Program. Participation figures include enrollment in Puerto Rico (averaging 1.3
  to 1.5 million persons a month under the nutrition assistance grant and higher figures in earlier years).
  Average benefit figures do not reflect somewhat lower benefits in Puerto Rico under its nutrition assistance
  grant.

 Note.--Figures in this table have been revised from similar tables presented in earlier versions of the Green
  Book to reflect more recent spending information and more precise inflation adjustments for constant dollar
  amounts.

 Source: Compiled by the Congressional Research Service.

                                MEDICAID

     Medicaid, authorized under title XIX of the Social
Security Act, is a Federal-State matching entitlement program
providing medical assistance to low-income persons who are
aged, blind, disabled, members of families with dependent
children, and certain other pregnant women and children. Within
Federal guidelines, each State designs and administers its own
program. Thus, there is substantial variation among States in
coverage, types and scope of benefits offered, and amounts of
payments for services. Recent legislation has expanded the
authority of States to decide who should be eligible for
Medicaid, changed the rules governing Medicaid reimbursement to
hospitals and community health centers, and increased States'
flexibility to enroll Medicaid recipients into managed care
programs.

                               Eligibility

     Medicaid does not provide medical assistance to all poor
persons. States are required to serve some population groups
and are permitted to serve others. In general, eligibility for
Medicaid is limited to low-income children and pregnant women,
adults in families with dependent children, low-income persons
with disabilities, and low-income elderly persons. Applicants'
income and assets must be within program financial standards.
For some population groups, these standards vary among States.
For others, standards are set by Federal law. Medicaid is
available to two broad classes of eligible persons: the
``categorically needy'' and the ``medically needy.'' The two
terms once distinguished between welfare-related beneficiaries
and those qualifying only under special Medicaid rules.
However, nonwelfare groups have been added to the
``categorically needy'' list over the years, and recent
legislation has partially severed the automatic connection
between Medicaid and welfare. As a result, the terms are no
longer especially helpful in sorting out the various
populations for whom mandatory or optional Medicaid coverage
has been made available, and some analysts believe they should
be abandoned. However, the distinction between the
categorically and medically needy is still an important one
because the scope of covered services that States must provide
to the categorically needy is much broader than the minimum
scope of services for the medically needy.
     All States must cover certain mandatory groups of
categorically needy individuals.\10\ Coverage of additional
categorically needy groups is optional, as is coverage of the
medically needy. The following discussion describes the
mandatory and optional categorically eligible groups; the
medically needy are discussed separately at the end of this
section.
---------------------------------------------------------------------------
    \10\ Arizona does not operate a traditional Medicaid Program. Since
1982 it has operated a federally assisted medical assistance program
for low-income persons under a demonstration waiver.
---------------------------------------------------------------------------

                           Categorically Needy

 Families, Pregnant Women, and Children
     Prior to the enactment of the Personal Responsibility and
Work Opportunities Act of 1996 (PRWORA, Public Law 104-193),
there were two major routes to Medicaid for low-income women
and children. The first was through cash welfare: individuals
who qualified for Aid to Families with Dependent Children
(AFDC) cash assistance or Supplemental Security Income (SSI)
were automatically eligible for Medicaid. The second was
through legislation in the last decade that extended coverage
to low-income pregnant women and children who have no ties to
the welfare system. PRWORA replaced the AFDC Program with a
block grant to States for Temporary Assistance for Needy
Families (TANF), severing the automatic connection between cash
assistance and Medicaid.
 AFDC-related groups
     Prior to the enactment of the Personal Responsibility and
Work Opportunities Act of 1996, States were required to provide
Medicaid to all persons receiving cash assistance under AFDC,
as well as to additional AFDC-related groups that did not
actually receive cash payments. These groups included: persons
who did not receive a payment because the amount would be less
than $10; persons whose payments were reduced to zero because
of recovery of previous overpayments; certain work
supplementation participants; certain children for whom
adoption assistance agreements were in effect or for whom
foster care payments were being made under title IV-E of the
Social Security Act; and persons who were ineligible for AFDC
because of a requirement that could not be imposed under
Medicaid.
     States were required to continue Medicaid for specified
periods for certain families who lost AFDC benefits after
receiving them in at least 3 of the preceding 6 months. If the
family lost AFDC benefits because of increased income from
earnings or hours of employment, Medicaid coverage had to be
extended for 12 months. (During the second 6 months a premium
could be imposed, the scope of benefits could be limited, or
alternate delivery systems could be used.) If the family lost
AFDC because of increased child or spousal support, coverage
had to be extended for 4 months. States were also required to
furnish Medicaid to certain two-parent families whose principal
earner was unemployed and who did not receive cash assistance
because the State was one of those permitted (under the Family
Support Act of 1988) to set a time limit on AFDC coverage for
such families.
     States were permitted, but not required, to provide
coverage to additional AFDC-related groups. The most important
of these were the ``Ribicoff children,'' whose income and
resources were within AFDC standards but who did not meet the
definition of ``dependent child.'' States could cover these
children up to a maximum age of 21, and could limit coverage to
reasonable subgroups, such as children in privately subsidized
foster care, or those who lived in certain institutional
settings. States could also furnish Medicaid to persons who
would have received AFDC if the State's AFDC Program were as
broad as permitted under Federal law.
     PRWORA repealed the AFDC Program, replacing it with the
block grant program Temporary Assistance for Needy Families
(TANF). Unlike AFDC, TANF eligibility does not confer automatic
Medicaid eligibility. Although the automatic link between AFDC
and Medicaid has been broken, the new law preserves Medicaid
entitlement for individuals who meet the requirements for the
AFDC Program that were in their State on July 16, 1996, even if
they do not qualify for assistance under TANF. States are
required to use the eligibility determination process already
in place for AFDC and Medicaid, including the same income and
resource standards and other rules formerly used to determine
if a family's income and composition made them eligible for
AFDC and Medicaid. States must continue Medicaid assistance for
recipients of adoption assistance and foster care under title
IV-E of the Social Security Act. As under prereform law, if a
family becomes ineligible for Medicaid because of earnings or
child or spousal support income and received Medicaid in three
of the preceding 6 months, the family is eligible for a period
of transitional Medicaid assistance. States also may continue
Medicaid coverage to children up to age 21 who meet what were
the AFDC income and resources requirements in effect in their
State on July 16, 1996, but do not meet the definition of
dependent child. States are permitted to deny Medicaid benefits
to nonpregnant adults and heads of households who lose TANF
benefits because of refusal to work, but must continue to
provide Medicaid coverage to their children.
     PRWORA allows States to modify their ``prereform'' AFDC
income and resource standards as follows: (1) States may lower
their income eligibility standards, but not below those it used
on May 1, 1988; (2) States may increase their income and
resource standards up to the percentage increase in the
Consumer Price Index (CPI); (3) States may use less restrictive
income and resource standards than those in effect on July 16,
1996.
 Poverty level pregnant women and children
     Between 1986 and 1991, Congress gradually extended
Medicaid to groups of pregnant women and children defined in
terms of family income, rather than in terms of their ties to
the AFDC Program.
     States are required to cover pregnant women and children
under age 6 with family incomes below 133 percent of the
Federal poverty income guidelines. In 1997, the poverty
guideline in the 48 contiguous States and the District of
Columbia is $13,330 for a family of three. Coverage for
pregnant women is limited to services related to the pregnancy
or complications of the pregnancy. Eligibility extends to 60
days after termination of the pregnancy. Children receive full
Medicaid coverage.
     Since July 1, 1991, States have been required to cover all
children who are under age 19, who were born after September
30, 1983, and whose family income is below 100 percent of the
Federal poverty level. The 1983 start date means that the age
of mandatory coverage will increase each year until reaching
age 18 in fiscal year 2002.
     States are permitted, but not required, to cover pregnant
women and infants under 1 year old not covered under the
mandatory rules whose family income is no more than 185 percent
of the Federal poverty level. As of August 1996, 30 States and
the District of Columbia made use of this option to cover
pregnant women and infants with family incomes over 133 percent
of poverty. States wishing to further expand eligibility have
several options under Medicaid law, including waivers of
Federal rules. As of August 1996, six States had expanded
eligibility to pregnant women, infants, or children in families
with incomes over 185 percent of the Federal poverty level.
     The recently enacted Balanced Budget Act of 1997 (BBA
1997), Public Law 105-33, gives States the option to provide 12
months continuous Medicaid coverage for children regardless of
whether they continue to meet income eligibility tests and to
presume eligibility for low-income children, allowing the
States to provide services during the time that eligibility is
determined.

                       Aged and Disabled Persons

SSI-related groups
    States are generally required to cover recipients of SSI.
However, States may use more restrictive eligibility standards
for Medicaid than those for SSI if they were using those
standards on January 1, 1972 (before the implementation of
SSI). States that have chosen to apply at least one more
restrictive standard are known as ``section 209(b)'' States,
after the section of the Social Security Amendments of 1972
(Public Law 92-603) that established the option. These States
may vary in their definition of disability, or in their
standards related to income or resources. There are 12 section
209(b) States:

Connecticut
Hawaii
Illinois
Indiana
Minnesota
Missouri
New Hampshire
North Carolina
North Dakota
Ohio
Oklahoma
Virginia

    States using more restrictive income standards must allow
applicants to deduct medical expenses from income (not
including SSI or State supplemental payments, SSP) in
determining eligibility. This process is known as ``spend
down.'' For example, if an applicant has a monthly income of
$400 (not including any SSI or SSP) and the State's maximum
allowable income is $350, the applicant would be required to
incur $50 in medical expenses before qualifying for Medicaid.
As will be discussed below, the spend down process is also used
in establishing eligibility for the medically needy.
    States must continue Medicaid coverage for several defined
groups of individuals who have lost SSI or SSP eligibility. The
``qualified severely impaired'' are disabled persons who have
returned to work and have lost eligibility as a result of
employment earnings, but still have the condition that
originally rendered them disabled and meet all nondisability
criteria for SSI except income (the current law threshold for
earnings is $1,053 per month). Medicaid must be continued if
such an individual needs continued medical assistance to
continue employment and the individual's earnings are
insufficient to provide the equivalent of SSI, Medicaid, and
attendant care benefits the individual would qualify for in the
absence of earnings. States must also continue Medicaid
coverage for persons who were once eligible for both SSI and
Social Security payments and who lose SSI because of a cost of
living adjustment (COLA) in their Social Security benefits.
Similar Medicaid continuations have been provided for certain
other persons who lose SSI as a result of eligibility for or
increases in Social Security or veterans benefits. Finally,
States must continue Medicaid for certain SSI-related groups
who received benefits in 1973, including ``essential persons''
(persons who care for a disabled individual).
     States are permitted to provide Medicaid to individuals
who are not receiving SSI but are receiving State-only
supplementary cash payments. Effective August 1997, States have
the option of creating a new eligibility category for disabled
SSI beneficiaries with incomes up to 250 percent of poverty.
Beneficiaries can ``buy into'' Medicaid by paying a sliding
scale premium based on the individual's income as determined by
the State.
 Qualified Medicare beneficiaries and related groups
     Effective January 1, 1991, States must provide limited
Medicaid coverage for ``qualified Medicare beneficiaries''
(QMBs). These are aged and disabled persons who are receiving
Medicare, whose income is below 100 percent of the Federal
poverty level ($7,890 for an individual and $10,610 for a
couple in 1997), and whose resources do not exceed twice the
allowable amount under SSI ($4,000 for an individual and $6,000
for a couple). States must pay Medicare part B premiums (and,
if applicable, part A premiums) for QMBs, along with required
Medicare coinsurance and deductible amounts.
     In addition, all States must pay part B premiums (but not
part A premiums or part A or B coinsurance and deductibles) for
``specified low-income Medicare beneficiaries'' (SLMBs). These
are beneficiaries who would be QMBs except that their incomes
are between 100 and 120 percent of the poverty level. Beginning
January 1998, the income eligibility level for the SLMB Program
will increase to 135 percent of poverty and States will be
required to cover a portion of the part B premium for Medicare
beneficiaries with incomes between 135 percent and 175 percent
of poverty.
     States also are required to pay part A premiums, but no
other expenses, for ``qualified disabled and working
individuals.'' These are persons who formerly received Social
Security disability benefits and hence Medicare, have lost
eligibility for both programs, but are permitted under Medicare
law to continue to receive Medicare in return for payment of
the part A premium. Medicaid must pay this premium on behalf of
such individuals who have incomes below 200 percent of poverty
and resources no greater than twice the SSI standard.
     States are permitted to provide full Medicaid benefits,
rather than just Medicare premiums and cost sharing, to QMBs
who meet a State-established income standard that is no higher
than 100 percent of the Federal poverty level. Seven States
make use of this option.
Institutionalized persons and related groups (all optional)
     States may provide Medicaid to certain otherwise
ineligible groups of persons who are in nursing facilities or
other institutions, or who would require institutional care if
they were not receiving alternative services at home or in the
community.
     States may establish a special income standard for
institutionalized persons, not to exceed 300 percent of the
maximum SSI benefits payable to a person who is living at home
and has no other resources. States may also provide Medicaid to
persons who would qualify for SSI but for the fact that they
are in an institution.
     A State may obtain a waiver under section 2176 of OBRA
1981 to provide home and community-based services to a defined
group of individuals who would otherwise require institutional
care.\11\ Persons served under such a waiver may receive
Medicaid coverage if they would be eligible if they lived in an
institution. Such individuals may also be covered in a State
that terminates its waiver program in order to take advantage
of a new, no-waiver home and community-based services option
created by OBRA 1990.
---------------------------------------------------------------------------
    \11\ These waivers are also known as 1915(c) waivers.
---------------------------------------------------------------------------
     A State may also provide Medicaid to several other classes
of persons who need the level of care provided by an
institution and who would be eligible if they were in an
institution. These include children being cared for at home,
persons of any age who are ventilator-dependent, and persons
receiving hospice benefits in lieu of institutional services.
 Aliens
     Legal immigrants arriving in the United States after
August 22, 1996 are ineligible for Medicaid benefits for 5
years. Coverage of such persons after the 5 year ban is a State
option. States are required to provide Medicaid coverage to
legal immigrants who resided in the country and were receiving
benefits on August 22,1996, and for those residing in the
country as of that date who become disabled in the future.
States are also required to provide coverage to: refugees for
the first 7 years after entry into the United States; asylees
for the first 7 years after asylum is granted; individuals
whose deportation is being withheld by the Immigration and
Naturalization Service for the first 7 years after grant of
deportation withholding; lawful permanent aliens after they
have been credited with 40 quarters of coverage under Social
Security; and honorably discharged U.S. military veterans,
active duty military personnel, and their spouses and unmarried
dependent children. Qualified aliens and nonqualified aliens
who meet the financial and categorical eligibility requirements
for Medicaid may receive emergency Medicaid services.

                          The Medically Needy

    Forty States and other jurisdictions provide Medicaid to at
least some groups of ``medically needy'' persons. These are
persons who meet the nonfinancial standards for inclusion in
one of the groups covered under Medicaid, but who do not meet
the applicable income or resource requirements for
categorically needy eligibility. The State may establish higher
income or resource standards for the medically needy. In
addition, individuals may spend down to the medically needy
standard by incurring medical expenses, in the same way that
SSI recipients in section 209(b) States may spend down to
Medicaid eligibility. For the medically needy, spend down may
involve the reduction of assets and income.
    The State may set its separate medically needy income
standard for a family of a given size at any level up to 133
percent of the maximum payment for a similar family under the
State's AFDC Program as in place on July 16, 1996. States may
limit the groups of individuals who may receive medically needy
coverage. If the State provides any medically needy program,
however, it must include all children under 18 who would
qualify under one of the mandatory categorically needy groups,
and all pregnant women who would qualify under either a
mandatory or optional group, if their income or resources were
lower.
    As of October 1, 1995, the following 40 States and
territories covered some groups of the medically needy:

American Samoa
Arkansas
California
Connecticut
District of Columbia
Florida
Georgia
Hawaii
Illinois
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Montana
Nebraska
New Hampshire
New Jersey
New York
North Carolina
North Dakota
Northern Mariana Islands
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin

                         Medicaid and the Poor

     In 1996, Medicaid covered 12 percent of the total U.S.
population (excluding institutionalized persons) and 44.6
percent of those with incomes below the Federal poverty level.
Because categorical eligibility requirements for children are
less restrictive than those for adults, poor children are much
more likely to receive coverage. Table 15-12 shows Medicaid
coverage by age and income status in 1995, as reported in the
March 1996 Current Population Survey (CPS) conducted by the
Census Bureau. Note that persons shown as receiving Medicaid
may have had other health coverage as well. Nearly all the
elderly, for example, have Medicare and/or private coverage.
     Children under age 6 with family incomes below poverty are
most likely to be covered. Coverage rates drop steadily with
age and income until age 65.

                                Services

     States are required to offer the following services to
categorically needy recipients under their Medicaid Programs:
inpatient and outpatient hospital services; laboratory and x-
ray services; nursing facility (NF) services for those over age
21; home health services for those entitled to NF care; early
and periodic screening, diagnosis, and treatment (EPSDT) for
those under age 21; family planning services and supplies;
physicians' services; and nurse-midwife services. OBRA 1989
required States to provide ambulatory services offered by
federally qualified health centers, effective April 1, 1990,
and services furnished by certified family or pediatric nurse
practitioners, effective July 1, 1990. States may also provide
additional medical services such as drugs, eyeglasses, and
inpatient psychiatric care for individuals under age 21 or over
65 (see table 15-24).

     TABLE 15-12.--MEDICAID COVERAGE BY AGE AND FAMILY INCOME, 1995
                             [In thousands]
------------------------------------------------------------------------
                                                               Percent
               Age                  Covered by   Persons in      with
                                     Medicaid    age group     Medicaid
------------------------------------------------------------------------
In poverty:
    0-5..........................        4,131        5,854         70.6
    6-10.........................        2,687        4,228         63.5
    11-18........................        2,785        5,555         50.1
    19-44........................        4,598       13,770         33.4
    45-64........................        1,546        4,764         32.4
    65 or older..................        1,008        3,355         30.0
                                  --------------------------------------
      Total......................       16,750       37,530         44.6
                                  ======================================
Family income between 100 and 133
 percent of poverty:
    0-5..........................          842        1,804         46.7
    6-10.........................          558        1,545         36.1
    11-18........................          677        2,267         29.9
    19-44........................        1,177        6,202         19.0
    45-64........................          415        2,281         18.2
    65 or older..................          495        3,093         16.0
                                  --------------------------------------
      Total......................        4,163       17,190         24.2
                                  ======================================
Family income between 133 and 185
 percent of poverty:
    0-5..........................          951        2,879         33.0
    6-10.........................          467        2,299         20.3
    11-18........................          607        3,136         19.4
    19-44........................        1,095       10,060         10.9
    45-64........................          343        3,452          9.9
    65 or older..................          376        4,766          7.9
                                  --------------------------------------
      Total......................        3,839       26,590         14.4
                                  ======================================
Family income greater than 185
 percent of poverty:
    0-5..........................        1,189       13,650          8.7
    6-10.........................          797       11,490          6.9
    11-18........................        1,098       19,480          5.6
    19-44........................        1,974       75,190          2.6
    45-64........................          867       42,170          2.1
    65 or older..................          942       20,440          4.6
                                  --------------------------------------
      Total......................        6,867      182,400          3.8
                                  ======================================
All persons:
    0-5..........................        7,112       24,186         29.4
    6-10.........................        4,508       19,563         23.0
    11-18........................        5,166       30,437         17.0
    19-44........................        8,843      105,222          8.4
    45-64........................        3,171       52,667          6.0
    65 or older..................        2,820       31,654          8.9
                                  --------------------------------------
      Total......................       31,618      263,710        12.0
------------------------------------------------------------------------
Source: CRS tabulations from the March 1996 Current Population Survey
  (CPS). Table excludes persons in institutions and approximately
  250,000 children under age 15 living with nonfamily caretakers. Number
  of recipients is lower than the number on administrative records due
  to underreporting by CPS respondents.

     Federal law establishes the following requirements for
coverage of the medically needy: (1) if a State provides
medically needy coverage to any group, it must provide
ambulatory services to children and prenatal and delivery
services for pregnant women; (2) if a State provides
institutional services for any medically needy group, it must
also provide ambulatory services for this population group; and
(3) if the State provides medically needy coverage for persons
in intermediate care facilities for the mentally retarded (ICF/
MRs) or in institutions for mental diseases, it must offer to
all groups covered in its medically needy program either all of
the mandatory services or alternatively the care and services
listed in 7 of the 25 paragraphs in the law defining covered
services.

                                Financing

     The Federal Government helps States pay the cost of
Medicaid services by means of a variable matching formula which
is adjusted annually. The Federal matching rate, which is
inversely related to a State's per capita income, can range
from 50 to 83 percent, though, in 1997, the highest rate is
77.22 percent, with 11 States and the District of Columbia
receiving the minimum match of 50 percent. Beginning in fiscal
year 1998 the Federal matching rate for the District of
Columbia will increase permanently to 70 percent; Alaska's
matching percentage will increase to 59.8 percent for fiscal
years 1998, 1999, and 2000. Federal matching for the
territories is set at 50 percent with a maximum dollar limit
placed on the amount each territory can receive. The Federal
share of administrative costs is 50 percent for all States
except for certain items where the authorized rate is higher.

                          Reimbursement Policy

     States establish their own service reimbursement policies
within general Federal guidelines. OBRA 1989 codified the
regulatory requirement that payments must be sufficient to
enlist enough providers so that covered services will be
available to Medicaid beneficiaries at least to the extent they
are available to the general population in a geographic area.
Beginning April 1, 1990, States were required to submit to the
Secretary their payment rates for pediatric and obstetrical
services along with additional data that would assist the
Secretary in evaluating the State's compliance with this
requirement. Effective October 1, 1997, States no longer must
assure adequate payment levels to obstetricians and
pediatricians nor provide annual reports on their payment
levels for these services.
     Until 1980, States were required to follow Medicare rules
in paying for institutional services. The Boren amendment,
enacted with respect to nursing homes in 1980 and extended to
hospitals in 1981, authorized States to establish their own
payment systems, as long as rates were reasonable and adequate
to meet the costs of efficiently and economically operated
facilities. Rates for hospitals had to also be sufficient to
assure reasonable access to inpatient services of adequate
quality. BBA 1997 repeals the Boren amendment. Effective
October 1, 1997, States must instead provide public notice of
the proposed rates for hospitals, nursing facilities, and ICFs/
MR and the methods used to establish those rates.
     State hospital reimbursement systems must provide for
additional payments to facilities serving a disproportionate
share of low-income patients. Unlike the comparable Medicare
payments, Medicaid payments must follow a formula that
considers a hospital's charity patients as well as its Medicaid
caseload.
     OBRA 1990 established new rules for Medicaid reimbursement
of prescription drugs. The law denies Federal matching funds
for drugs manufactured by a firm that has not agreed to provide
rebates. Under amendments made by the Veterans Health Care Act
of 1992, a manufacturer is not deemed to have a rebate
agreement unless the manufacturer has entered into a master
agreement with the Secretary of Veterans Affairs. Rebate
amounts vary depending on the nature of the drug. The minimum
rebate is 11 percent of the average price. OBRA 1990
established a 4-year moratorium on reductions in most payment
rates for pharmacists.
     Practitioners and providers are required to accept
payments under the program as payment in full for covered
services except where nominal cost-sharing charges may be
required. States may generally impose such charges with certain
exceptions. They are precluded from imposing cost sharing on
services for children under 18, services related to pregnancy,
family planning or emergency services, and services provided to
nursing facility inpatients who are required to spend all of
their income for medical care except for a personal needs
allowance. Effective August 5, 1997 States are permitted to pay
Medicaid rates to providers for services to ``dual eligibles''
(those Medicare beneficiaries who are also eligible for full
Medicaid benefits) and qualified Medicare beneficiaries (QMBs).
State Medicaid Programs are not required to pay Medicare cost-
sharing expenses for these persons if the Medicare payment for
the service exceeds the amount that the State Medicaid Program
would have paid for the service to a recipient who was not a
dual eligible or QMB.

                             Administration

     Medicaid is a State-administered program. At the Federal
level, the Health Care Financing Administration (HCFA) of the
Department of Health and Human Services is responsible for
overseeing State operations.
     Federal law requires that a single State agency be charged
with administration of the Medicaid Program. Generally, that
agency is either the State welfare agency, the State health
agency, or an umbrella human resources agency. The single State
agency may contract with other State entities to conduct some
program functions. Further, States may process claims for
reimbursement themselves or contract with fiscal agents or
health insuring agencies to process these claims.

                        Medicaid and Managed Care

     To contain escalating health care costs and improve access
to the Medicaid Program, States are increasingly adopting
managed care delivery systems. Between 1991 and 1996,
enrollment in Medicaid managed care increased by nearly 400
percent. According to the Health Care Financing Administration
(HCFA), by 1996, 13.3 million Medicaid beneficiaries
representing 40 percent of the total Medicaid population were
enrolled in some form of managed care. Medicaid managed care
refers to a system of health care delivery where the provision
of an agreed upon set of Medicaid-covered health care services
is coordinated by a health plan or a primary care case manager.
These plans, or case managers, are obligated by contract or
agreement to be responsible for the care provided (or not
provided) to enrollees. The goal of managed care systems is to
provide access to quality health care while containing costs by
ensuring that all necessary services are provided to
individuals.
     Until recently, States wishing to require Medicaid
beneficiaries to enroll in managed care plans had to obtain one
of two types of waivers from the HCFA. States could operate
voluntary managed care programs without a waiver. The first
type of waiver, known as a ``freedom-of-choice'' waiver, is
permitted by section 1915(b) of the Social Security Act.
Section 1915(b) waivers allow States to waive specific
requirements for a specific population or geographical area,
and have been used to require Medicaid beneficiaries to enroll
in managed care plans and to restrict the providers from whom
enrollees receive Medicaid-covered services. There are
currently some 100 freedom-of-choice programs operating in 42
States. The second, a section 1115(a) waiver, offers States the
greatest flexibility, allowing HCFA to waive a broad range of
Medicaid requirements. As of October 1997, statewide section
1115(a) waivers were approved in 18 States, implemented in 15,
and pending in eight States. In addition to permitting States
to require Medicaid beneficiaries to enroll in managed care and
to restrict their choice of providers, these waivers allow
States to expand coverage to those not traditionally eligible
for Medicaid, to impose premiums and copayments on those new
eligibles, and to modify the Medicaid benefit package. Section
1115(a) waivers are approved on condition that they are budget
neutral to the Federal Government--that Federal costs over the
life of the waiver (typically 5 years) are no more than if the
State had continued operating its prewaiver Medicaid Program.
To enforce budget neutrality, some waivers employ aggregate
caps on Federal matching and others use per capita expenditure
caps. Some States exempt aged, blind, and disabled Medicaid
eligibles, who often incur high medical expenses, from
mandatory managed care participation. Most Medicaid managed
care programs have operated under waiver authorities allowed by
Medicaid statute.
     Medicaid managed care programs generally fall into two
categories: those where the health plan assumes full financial
risk for services it provides to enrollees, referred to as
``risk-based'' programs; and those where an individual health
care provider (a physician or other licensed health
professional) is paid a small monthly amount by the State in
return for managing health care services for a defined
population, referred to as ``primary care case management
(PCCM)'' programs. In the latter case, the provider acts as a
gatekeeper for services needed by an individual, but does not
assume financial risk for health care services provided. As of
July 1996, 38 States had risk-based programs, and 32 States had
PCCM programs (National Academy for State Health Policy, 1997,
p. 2).
     The Medicaid population covered by State managed care
programs is composed primarily of low-income women and
children. As of July 1996, all States operating risk-based
programs enrolled the AFDC-related population; 36 enrolled
poverty-level children; and 33 enrolled poverty-level pregnant
women (p. 32). Some States enroll populations with more complex
medical needs, such as the noninstitutionalized elderly, and
persons with mental and physical disabilities. As of July 1996,
20 States covered the noninstitutional elderly in their risk-
based programs; 24 covered SSI eligible children; and 23
covered SSI eligible adults living in the community. In
general, States tend to require risk-based managed care plans
to provide a comprehensive range of Medicaid-covered services.
The exception to this are long-term care services needed by the
elderly and disabled, which generally are not included under
managed care, and behavioral health services, which are
sometimes provided under a separate contract. This is in
contrast to States that operate PCCM programs, where most
States limit the PCCM providers to gatekeeper functions for a
smaller range of services.
     The Balanced Budget Act of 1997 (BBA 1997) included
several provisions that will significantly affect the operation
of State Medicaid managed care programs. Effective October 1,
1997, States no longer need a waiver of Federal law to require
the majority of Medicaid beneficiaries to enroll in managed
care. Waivers are still required to mandate the enrollment of
children with special health care needs, Native Americans/
Alaskan Natives, and dual-eligible Medicaid-Medicare
beneficiaries. BBA 1997 permits States to contract with managed
care organizations serving only Medicaid beneficiaries and to
``lock'' beneficiaries into the same plan for up to 12 months.
Prior to the new law, States required a 1115 waiver to
implement these requirements. BBA 1997 establishes new rules
intended to safeguard the quality of care provided under
managed care arrangements. These include provisions related to
enrollment and disenrollment; information that States must
provide enrollees and potential enrollees; assurances of
adequate capacity and access to care; balance billing
protections; solvency standards; marketing materials; grievance
procedures; and other quality assurance standards the Secretary
of HHS is charged with developing. The law adopts the ``prudent
layperson'' standard to whether a Medicaid managed care
organization would have to pay for services provided to an
enrollee in an emergency room and includes a ban on so-called
``gag rules,'' prohibiting interference with physician advice
to enrollees.

                          Legislative History

    The following is a summary of the major Medicaid changes
enacted as part of the Omnibus Budget Reconciliation Act of
1990 (OBRA 1990), Public Law 101-508:
 1. Reimbursement for prescribed drugs.--The law requires
        manufacturers of prescription drugs to provide rebates
        to State Medicaid Programs. States are required to
        cover all the drugs manufactured by a firm entering
        into a rebate agreement. The minimum rebate is 10
        percent of the average manufacturer price for the
        product. Beginning in 1993, States are required to have
        prospective (i.e., point-of-sale) and retrospective
        drug utilization review (DUR) programs, to assure that
        prescriptions are appropriate and medically necessary.
        Until the end of 1993, enhanced Federal matching
        payments were provided for State administrative costs
        related to the rebate and DUR programs. The law
        establishes a 4-year moratorium on reductions in most
        payment rates for pharmacists.
 2. Required payment of premiums and cost sharing for
        enrollment under group health plans where cost
        effective.--Effective January 1, 1991, the law requires
        States to pay premiums for group health plans for which
        Medicaid beneficiaries are eligible, when it is cost
        effective to do so. States pay any cost sharing
        required by a plan and continue to furnish any Medicaid
        benefits not covered under the plan. Providers under
        group health plans are required to accept plan payment
        as payment in full for Medicaid enrollees.
 3. Protection of low-income Medicare beneficiaries.--The law
        accelerates phase in of the requirement that States pay
        Medicare premiums and cost sharing for QMBs, Medicare
        beneficiaries with incomes below 100 percent of the
        Federal poverty level. For all but five States, the
        requirement was effective January 1, 1991. All States
        must pay part B premiums (but not part A premiums or
        cost sharing) for beneficiaries with incomes below 120
        percent of the poverty level beginning in 1995.
 4. Child health provisions.--Effective July 1, 1991, all
        States are required to cover children under age 19 who
        were born after September 30, 1983, and whose family
        income is below 100 percent of the Federal poverty
        level. States are required to accept Medicaid
        applications for mothers and children at locations
        other than welfare offices, and are required to
        continue benefits for pregnant women until 2 months
        after the end of the pregnancy, and for infants through
        the first year of life. States are required to make
        additional payments for outlier cases and are
        prohibited from imposing durational limits on coverage
        for patients who are under age 1 in any hospital or
        under age 6 in a disproportionate share hospital.
 5. Home and community-based care as optional service.--The law
        permits States to provide home and community-based
        services to functionally disabled Medicaid
        beneficiaries age 65 or over, effective the later of
        July 1, 1991, or 30 days after the publication of
        interim rules. States are permitted to limit
        eligibility for the services without waivers and thus
        to provide the services without meeting cost-
        effectiveness tests. Federal matching payments cannot
        exceed 50 percent of what it would have cost to provide
        Medicare nursing facility care to the same group of
        beneficiaries. Total Federal expenditures were limited
        to $580 million over the period fiscal years 1991-95.
 6. Community supported living arrangements.--The law permits
        between two and eight States to provide community
        supported living arrangement services to
        developmentally disabled individuals who live with
        their families or in small community residential
        settings, effective the later of July 1, 1991, or 30
        days after the publication of interim rules. Services
        include personal assistance, training and habilitation,
        and other services needed to help with activities of
        daily living. Total Federal expenditures were limited
        to $100 million over the period fiscal years 1991-95.
 7. Payments for COBRA continuation coverage.--The Consolidated
        Omnibus Budget Reconciliation Act of 1985 (COBRA,
        Public Law 99-272) provides that employees or
        dependents leaving an employee health insurance group
        in a firm with 20 or more employees must be offered an
        opportunity to continue buying insurance through the
        group for 18 to 36 months (depending on the reason for
        leaving the group). OBRA 1990 permits State Medicaid
        Programs to pay for COBRA continuation coverage, when
        it is cost effective to do so, effective January 1,
        1991. States may pay premiums for individuals with
        incomes below 100 percent of poverty and resources less
        than twice the SSI limit who are eligible for
        continuation coverage under a group health plan offered
        by an employer with 75 or more employees.
 8. Miscellaneous.--The law establishes demonstration projects
        in three to four States to test the effect of providing
        Medicaid to families with incomes below 150 percent of
        the Federal poverty level that do not meet categorical
        eligibility requirements, and projects in two States to
        provide Medicaid coverage for early intervention
        services for HIV-infected individuals who do not meet
        disability criteria. The law also includes new measures
        to ensure the quality of physician services under
        Medicaid, technical corrections in nursing home reform
        provisions, and numerous other technical and
        miscellaneous amendments.
    The following is a summary of the major changes enacted in
the Medicaid Voluntary Contribution and Provider-Specific Tax
Amendments of 1991, Public Law 102-234.
 1. Voluntary contributions and provider-specific taxes.--The
        law caps Federal matching payments for State Medicaid
        spending that is financed with revenues from provider
        donations or taxes. Generally effective January 1,
        1992, before the Federal share is computed, a State's
        expenditures for Medicaid are reduced by revenues
        received by a State or local government from provider-
        related donations, and health care-related taxes that
        are not broad based. Broad based taxes are those that
        are uniformly imposed on all providers in a class, or
        all businesses in a class furnished by the providers.
        States with non-broad-based taxes in effect or approved
        as of November 22, 1991, are permitted to continue them
        temporarily, but the taxes may not be increased. States
        with voluntary contribution programs in effect or
        reported as of September 30, 1991, for States' fiscal
        year 1992, may continue them temporarily but may not
        increase them. During fiscal years 1993-95, Federal
        matching funds for revenue from voluntary
        contributions, provider specific taxes, and broad-based
        taxes were limited to the greater of 25 percent of the
        State share of Medicaid expenditures or the amount of
        donations and taxes collected in the State in fiscal
        year 1992. Federal matching funds are allowable for
        certain donations. These are bona fide provider
        donations that are not related to Medicaid payments to
        the provider, and donations in the form of payment for
        outstationing Medicaid eligibility workers. Beginning
        in fiscal year 1993, the latter type of donations are
        limited to 10 percent of a State's Medicaid
        administrative costs.
 2. Payments for disproportionate share hospitals.--The law
        places an aggregate national cap of 12 percent of
        Medicaid expenditures on payment adjustments for
        disproportionate share hospitals (DSH). Beginning with
        fiscal year 1993, States with DSH payments of 12
        percent or more of total Medicaid expenditures in
        fiscal year 1992 cannot exceed this dollar level in the
        future; States with DSH payments of less than 12
        percent may increase them at the same rate as their
        overall Medicaid expenditure growth.
    Two 1991 acts concern enrollment in two health maintenance
organizations. The law specifies that no more than 75 percent
of the enrollees of an HMO may be Medicaid or Medicare
beneficiaries. Public Law 102-276 authorized a waiver of this
requirement for the Dayton Area Health Plan; Public Law 102-317
authorized a similar waiver for the Tennessee Primary Care
Network.
    The following is a summary of major Medicaid changes
enacted in the Veterans Health Care Act of 1992, Public Law
102-585, pertaining to Medicaid reimbursement policies for
prescription drugs.
 1. Calculation of best price.--The law excludes certain prices
        from calculation of best price (the lowest price
        available from a manufacturer) for Medicaid drug
        rebates. The law excludes the prices charged to the
        Indian Health Service, the Department of Veterans
        Affairs, veterans State homes, the Department of
        Defense, the Public Health Service and certain private
        and nonprofit hospitals, as well as any prices charged
        under the Federal Supply Schedule of the General
        Services Administration or under State pharmaceutical
        assistance programs.
 2. Rebate amounts.--The law changes the minimum basic rebates
        for brand name drugs to 15.7 percent of the average
        manufacturer price (AMP) in calendar year 1993, 15.4
        percent of the AMP in 1994, 15.2 percent of the AMP in
        1995, and 15.1 percent of the AMP thereafter. In each
        calendar year, the basic rebate is the greater of the
        percentage stated, or the difference between the AMP
        and the best price.
    The following is a summary of major Medicaid changes
enacted in the Omnibus Budget Reconciliation Act of 1993 (OBRA
1993), Public Law 103-66.
 1. Medicaid fraud control units.--The law changed the State
        option to a requirement that each State operate a
        Medicaid fraud and abuse control unit unless the State
        demonstrates that effective operation of a unit would
        not be cost effective and that, in the absence of a
        unit, beneficiaries would be protected from abuse and
        neglect.
 2. Prescription drug formularies.--States have been prohibited
        from using drug formularies (lists of covered and
        excluded drug products) and from imposing restrictions
        on new drug products for 6 months after a drug is
        approved by the Food and Drug Administration. States
        are allowed to use formularies to cover only the
        State's designated drug(s) in a class of therapeutic
        alternatives and impose certain requirements on
        prescriptions for new drugs.
 3. Asset and trust provisions.--Some individuals must spend
        their assets down to a State-established level before
        Medicaid pays for nursing facility and other medical
        care. To try to ensure that these persons apply their
        assets to the cost of their care and do not give them
        away in order to gain Medicaid eligibility sooner than
        they otherwise would, Medicaid prohibits persons from
        transferring assets for less than fair market value.
        OBRA 1993 amends Medicaid law to close loopholes that
        allow individuals to shelter or divest assets in order
        to become eligible for Medicaid-covered long-term care.
        States are required to provide for a delay in Medicaid
        eligibility for institutionalized persons or their
        spouses who dispose of assets for less than fair market
        value. A transfer that occurred during the 36-month
        period prior to an application for coverage would
        trigger a period of ineligibility beginning with the
        month the assets were transferred. Under the OBRA 1993
        amendments, the period of ineligibility is determined
        by comparing the cost of care and the fair market value
        of the assets transferred. States are required to seek
        recovery of Medicaid expenditures from the estate of a
        deceased beneficiary who received certain Medicaid
        benefits. Amounts paid by Medicaid for nursing facility
        services, home and community-based care, and related
        hospital and prescription drug services must be
        recovered from the estates of individuals who were over
        age 55 when such services were received. OBRA 1993
        provides for exemptions to these asset transfer and
        recovery provisions if application of the law would
        result in ``undue hardship'' according to criteria
        established by the Secretary.
 4. Child support enforcement.--A child who is covered by
        Medicaid may also be covered by private health
        insurance that is carried by a noncustodial parent. To
        improve medical support for children, Medicaid law is
        amended to mandate that States have laws in effect to
        require the cooperation of employers and insurers in
        obtaining parental coverage.
 5. Disproportionate share hospitals (DSH).--States are
        prohibited from designating a hospital as a DSH unless
        Medicaid beneficiaries account for at least 1 percent
        of the hospital's impatient days. In addition, the law
        requires that DSH payments to a State or locally owned
        or operated facility cannot exceed the costs the
        facility incurs in furnishing inpatient or outpatient
        service to Medicaid beneficiaries or uninsured
        patients. For this purpose, a facility's cost is net of
        payments received from Medicaid (other than DSH
        payments) and from uninsured individuals.
 6. Physician referral.--Medicaid payments for designated
        health services (including clinical laboratory,
        physical and occupational therapy, radiology, or other
        diagnostic services, home health and other services)
        are limited if such services are furnished upon
        referral from a physician who has a specified financial
        relationship with the provider furnishing the service.
 7. Childhood immunization.--A new entitlement program is
        established under which States are entitled to receive
        vaccines purchased by the Federal Government for
        federally eligible children up to age 18. Providers
        registered in a State's immunization program are
        entitled to receive free vaccines for children covered
        under the new law. Children eligible to receive
        federally purchased vaccines are Medicaid-eligible,
        American Indian or Alaska Native, children whose health
        insurance does not cover the cost of vaccines, and
        children who receive immunization at federally
        qualified health centers or rural health clinics.
 8. Tuberculosis-related services.--States are permitted to
        provide Medicaid coverage for outpatient tuberculosis-
        related services to tuberculosis-infected individuals
        who meet the income and resource limits that apply to
        disabled persons.
     The following is a summary of major Medicaid changes
enacted in the Contract with America Advancement Act of 1996,
Public Law 104-121:
 1. Alcoholics and drug addicts.--SSI benefits are terminated
        for individuals receiving disability cash assistance
        based on a finding of alcoholism and drug addiction.
        Persons who lose SSI eligibility, which gives them
        automatic Medicaid coverage, may still be eligible for
        Medicaid if they meet other Medicaid eligibility
        criteria. States are required to perform a
        redetermination of Medicaid eligibility in any case
        where an individual loses SSI and that determination
        affects his or her Medicaid eligibility.
     The following is a summary of major Medicaid changes
enacted in the Personal Responsibility and Work Opportunity Act
of 1996, Public Law 104-193:
 1. Eligibility.--A new cash welfare block grant to States,
        Temporary Aid for Needy Families (TANF), is
        established. The automatic link between AFDC and
        Medicaid is severed. Families who meets AFDC
        eligibility criteria as of July 16, 1996 are eligible
        for Medicaid, even if they do not qualify for TANF.
        States must use the same income and resource standards
        and other rules previously used to determine
        eligibility, and the prereform AFDC family composition
        requirement still must be met. A State may lower its
        income standard, but not below the standard it applied
        on May 1, 1988. A State may increase its income and
        resource standards up to the percentage increase in the
        Consumer Price Index (CPI) subsequent to July 16, 1996.
        States may use less restrictive methods for counting
        income and resources than were required by law as in
        effect on July 16, 1996. States are permitted to deny
        Medicaid benefits to adults and heads of households who
        lose TANF benefits because of refusal to work; States
        may not apply this requirement to poverty-related
        pregnant women and children.
 2. Disabled children.--The definition of disability used to
        establish the eligibility of children for SSI is
        narrowed. Children who lose SSI eligibility, which
        gives them automatic Medicaid coverage, may still be
        eligible for Medicaid if they meet other Medicaid
        eligibility criteria. States are required to perform a
        redetermination of Medicaid eligibility in any case
        where an individual loses SSI and that determination
        affects his or her Medicaid eligibility.
 3. Aliens.--For legal resident aliens and other qualified
        aliens who entered the United States on or after August
        22, 1996 whose coverage is not mandatory (e.g., they
        have been credited with 40 quarters of Social Security
        coverage), Medicaid is barred for 5 years. Except for
        emergency services, Medicaid coverage for such aliens
        entering before August 22, 1996 and coverage after the
        5 year ban are State options.
 4. Administration.--A State may use the same application form
        for Medicaid as they use for TANF. A State may choose
        to administer the Medicaid Program through the same
        agency that administers TANF or through a separate
        Medicaid agency. A special fund of $500 million is
        provided for enhanced Federal matching for States'
        expenditures attributable to the administrative costs
        of Medicaid eligibility determinations due to the law.
     The following is a summary of major Medicaid changes
enacted in the Balanced Budget Act of 1997, Public Law 105-33:
 1. Eligibility.--The Balanced Budget Act restores Medicaid
        eligibility and SSI coverage for legal immigrants who
        entered the country prior to August 22, 1996 and later
        become disabled; guarantees continued Medicaid
        eligibility for children with disabilities who are
        expected to lose their SSI eligibility as the result of
        restrictions enacted in 1996; and extends the exemption
        from the ban on Medicaid and other forms of public
        assistance for refugees and individuals seeking asylum
        from 5 to 7 years. States are permitted to provide
        continuous Medicaid coverage for 12 months to all
        children, regardless of whether they continue to meet
        income eligibility tests. States are permitted to
        create a new Medicaid eligibility category for
        individuals with incomes up to 250 percent of poverty
        and who would, but for income, be eligible for SSI.
        Such individuals can ``buy into'' Medicaid by paying a
        sliding scale premium based on the individuals' income
        as determined by the State.
 2. Payment methodology.--The law repeals the Boren amendment,
        which directed that payment rates to institutional
        providers be ``reasonable and adequate'' to cover the
        cost of ``efficiently and economically operated''
        facilities, and repeals the law requiring States to
        assure adequate payment levels for services provided by
        obstetricians and pediatricians. The requirement to pay
        federally qualified health centers and rural health
        clinics 100 percent of reasonable costs will be phased
        out over 6 fiscal years, with special payment rules in
        place during fiscal years 1998-2002 to ease the
        transition.
 3. Payments for disproportionate share hospitals.--The law
        reduces State DSH allotments by imposing freezes and
        making graduated proportionate reductions. Limitations
        are placed on payments to institutions for mental
        disease (IMDs). The act establishes additional caps on
        the State DSH allotments for fiscal years beginning in
        1998 and specifies those caps for 1998 to 2002. States
        are required to report annually on the method used to
        target DSH funds and to describe the payments made to
        each hospital.
 4. Managed care.--The law eliminates the need for 1915(b)
        waivers for most Medicaid populations. Under the new
        law, States can require the majority of Medicaid
        recipients to enroll in managed care simply by amending
        their State plan. Waivers are still required to mandate
        that children with special health care needs and
        certain dual eligibles Medicaid-Medicare beneficiaries
        enroll with managed care entities. The law establishes
        a statutory definition of primary care case management
        (PCCM), adds it as a covered service, and sets
        contractual requirements for both PCCM and Medicaid
        managed care organizations. The act also includes
        managed care provisions that establish standards for
        quality and solvency, and provide protections for
        beneficiaries. The law repeals the provision that
        requires managed care organizations to have no more
        than 75 percent of their enrollment be Medicaid and
        Medicare beneficiaries and the prohibition on cost
        sharing for services furnished by health maintenance
        organizations.

                              Program Data

    Under current law, Federal Medicaid outlays are projected
to reach $104.4 billion in fiscal year 1998, a 6-percent
increase over the $98.5 billion projected for fiscal year 1997.
This and other Medicaid Program data are presented in tables
15-13 to 15-24.

                            TABLE 15-13.--HISTORY OF MEDICAID PROGRAM COSTS, 1966-98
----------------------------------------------------------------------------------------------------------------
                                                          Total               Federal               State
                                                  --------------------------------------------------------------
                   Fiscal year                      Dollars              Dollars              Dollars
                                                      (in      Percent     (in      Percent     (in      Percent
                                                   millions)  increase  millions)  increase  millions)  increase
----------------------------------------------------------------------------------------------------------------
1966 \1\.........................................     $1,658  ........       $789  ........       $869  ........
1967 \1\.........................................      2,368      42.8      1,209      53.2      1,159      33.4
1968 \1\.........................................      3,686      55.7      1,837      51.9      1,849      59.5
1969 \1\.........................................      4,166      13.0      2,276      23.9      1,890       2.2
1970 \1\.........................................      4,852      16.5      2,617      15.0      2,235      18.3
1971.............................................      6,176      27.3      3,374      28.9      2,802      25.4
1972 \2\.........................................      8,434      36.6      4,361      29.3      4,074      45.4
1973.............................................      9,111       8.0      4,998      14.6      4,113       1.0
1974.............................................     10,229      12.3      5,833      16.7      4,396       6.9
1975.............................................     12,637      23.5      7,060      21.0      5,578      26.9
1976.............................................     14,644      15.9      8,312      17.7      6,332      13.5
    TQ \3\.......................................      4,106        NA      2,354        NA      1,752        NA
1977.............................................     17,103  \4\ 16.8      9,713  \4\ 16.9      7,389  \4\ 16.7
1978.............................................     18,949      10.8     10,680      10.0      8,269      11.9
1979.............................................     21,755      14.8     12,267      14.9      9,489      14.8
1980.............................................     25,781      18.5     14,550      18.6     11,231      18.4
1981.............................................     30,377      17.8     17,074      17.3     13,303      18.4
1982.............................................     32,446       6.8     17,514       2.6     14,931      12.2
1983.............................................     34,956       7.7     18,985       8.4     15,971       7.0
1984.............................................     37,569       7.5     20,061       5.7     17,508       9.6
1985 \5\.........................................     40,917       8.9  \6\ 22,65
                                                                                5      12.9  \6\ 18,26
                                                                                                     2       4.3
1986.............................................     44,851       9.6     24,995      10.3     19,856       8.7
1987.............................................     49,344      10.0     27,435       9.8     21,909      10.3
1988.............................................     54,116       9.7     30,462      11.0     23,654       8.0
1989.............................................     61,246      13.2     34,604      13.6     26,642      12.6
1990.............................................     72,492      18.4     41,103      18.8     31,389      17.8
1991.............................................     91,519      26.2     52,532      27.8     38,987      24.2
1992.............................................    118,166      29.1     67,827      29.1     50,339      29.1
1993.............................................    131,775      11.5     75,774      11.7     56,001      11.2
1994.............................................    143,204       8.7     82,034       8.3     61,170       9.2
1995.............................................    156,395       9.2     89,070       8.6     67,325      10.1
1996.............................................    161,963       3.6     91,990       3.3     69,973       3.9
1997 \7\.........................................    174,310       7.6     98,503       7.1     75,807       8.3
1998 \7\.........................................    184,712       6.0    104,384       6.0     80,328      6.0
----------------------------------------------------------------------------------------------------------------
\1\ Includes related programs which are not separately identified, though for each successive year a larger
  portion of the total represents Medicaid expenditures. As of January 1, 1970, Federal matching was only
  available under Medicaid.
\2\ Intermediate care facilities (ICFs) transferred from the cash assistance programs to Medicaid effective
  January 1, 1972. Data for prior periods do not include these costs.
\3\ Transitional quarter (beginning of Federal fiscal year moved from July 1 to October 1).
\4\ Represents increase over fiscal year 1976, i.e., five calendar quarters.
\5\ Includes transfer of function of State fraud control units to Medicaid from Office of Inspector General.
\6\ Temporary reductions in Federal payments authorized for fiscal years 1982-84 were discontinued in fiscal
  year 1985.
\7\ Current law estimate.

 NA--Not available.

 Note.--Totals may not add due to rounding.

 Source: Budget of the U.S. Government, fiscal years 1969-98 and Health Care Financing Administration.

     TABLE 15-14.--UNDUPLICATED NUMBER OF MEDICAID RECIPIENTS BY ELIGIBILITY CATEGORY, FISCAL YEARS 1972-95
                                             [Numbers in thousands]
----------------------------------------------------------------------------------------------------------------
                                                                                           Adults in
                                                                   Permanent   Dependent    family
         Fiscal year             Total     Age 65 or   Blindness   and total   children      with      Other \1\
                              recipients     over                  disabled    under age   dependent   title XIX
                                                                                  21       children
----------------------------------------------------------------------------------------------------------------
1972........................      17,606       3,318         108       1,625       7,841       3,137       1,576
1973........................      19,622       3,496         101       1,804       8,659       4,066       1,495
1974........................      21,462       3,732         135       2,222       9,478       4,392       1,502
1975........................      22,007       3,615         109       2,355       9,598       4,529       1,800
1976........................      22,815       3,612          97       2,572       9,924       4,774       1,836

1977 \2\....................      22,832       3,636          92       2,710       9,651       4,785       1,959
1978........................      21,965       3,376          82       2,636       9,376       4,643       1,852
1979........................      21,520       3,364          79       2,674       9,106       4,570       1,727
1980 \3\....................      21,605       3,440          92       2,819       9,333       4,877       1,499
1981 \3\....................      21,980       3,367          86       2,993       9,581       5,187       1,364

1982 \3\....................      21,603       3,240          84       2,806       9,563       5,356       1,434
1983 \3\....................      21,554       3,371          77       2,844       9,535       5,592       1,129
1984 \3\....................      21,607       3,238          79       2,834       9,684       5,600       1,187
1985 \3\....................      21,814       3,061          80       2,937       9,757       5,518       1,214
1986 \3\....................      22,515       3,140          82       3,100      10,029       5,647       1,362

1987 \3\....................      23,109       3,224          85       3,296      10,168       5,599       1,418
1988 \3\....................      22,907       3,159          86       3,401      10,037       5,503       1,343
1989 \3\....................      23,511       3,132          95       3,496      10,318       5,717       1,175
1990........................      25,255       3,202          83       3,635      11,220       6,010       1,105
1991........................      28,280       3,359          85       3,983      13,415       6,778         658

1992........................      30,926       3,742          84       4,378      15,104       6,954         664
1993........................      33,432       3,863          84       4,932      16,285       7,505         763
1994........................      35,053       4,035          87       5,372      17,194       7,586         779
1995........................      36,282       4,119          92       5,767      17,164       7,604      1,537
----------------------------------------------------------------------------------------------------------------
\1\ This category is composed predominantly of children not meeting the definition of ``dependent'' children,
  that is, ``Ribicoff children.''
\2\ Fiscal year 1977 began in October 1976 and was the first year of the new Federal fiscal cycle. Before 1977,
  the fiscal year began in July.
\3\ Beginning in fiscal year 1980, recipients' categories do not add to the unduplicated total due to the small
  number of recipients that are in more than one category during the year.

 Source: Health Care Financing Administration, U.S. Department of Health and Human Services.

                                  TABLE 15-15.--MEDICAID RECIPIENTS BY BASIS OF ELIGIBILITY BY STATE, FISCAL YEAR 1995
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                  Total                                                AFDC                  Other title
                            State                               recipients      Aged        Blind       Disabled     children   AFDC adults       IX
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama......................................................      539,251       71,301        1,515      129,850      243,999       88,912        2,879
Alaska.......................................................       68,117        4,464           90        6,578       38,834       18,151           --
Arizona......................................................      493,693       24,651          792       60,748      296,550      110,952           --
Arkansas.....................................................      353,370       52,618        1,239       86,160      119,702       58,665       31,644
California...................................................    5,016,645      486,356       25,645      716,667    2,198,066    1,377,013       93,680
Colorado.....................................................      293,723       36,851          121       49,345      128,301       71,962           --
Connecticut..................................................      380,327       66,428          317       49,498      177,792       86,285            7
Delaware.....................................................       78,555        6,102          114       12,528       42,830       15,947          632
District of Columbia.........................................      138,444        8,021          168       23,733       73,181       33,264           77
Florida......................................................    1,735,141      211,814        3,206      272,622      996,873      209,152       41,474
Georgia......................................................    1,147,443      103,985       14,020      177,401      597,092      244,346          100
Hawaii.......................................................       51,674       17,366           15       13,664       11,229        7,658           --
Idaho........................................................      115,014        9,337           51       18,432       61,850       24,785          559
Illinois.....................................................    1,551,949      127,142        1,368      275,631      763,633      331,662       52,513
Indiana......................................................      559,020       65,968        1,029       66,466      297,569      109,870        9,326
Iowa.........................................................      304,304       37,978          543       49,514      140,081       74,056          743
Kansas.......................................................      255,702       25,739          139       39,040      129,222       55,611            7
Kentucky.....................................................      640,930       63,219        1,817      154,518      270,303      125,936           --
Louisiana....................................................      785,399      102,421        1,718      158,416      376,075      146,769           --
Maine........................................................      153,180       19,404          230       31,741       65,978       31,299        3,977
Maryland.....................................................      414,261       47,957          318       85,320      196,813       73,724       10,129
Massachusetts................................................      727,506      103,504        6,879      153,622      310,943      152,558           --
Michigan.....................................................    1,168,435       86,101        2,016      220,836      543,287      300,692        3,036
Minnesota....................................................      473,420       63,098          617       74,953      234,174      100,578           --
Mississippi..................................................      519,697       66,639        1,558      124,253      247,312       76,328        2,076
Missouri.....................................................      695,458       92,948        1,115       96,592      347,712      155,552           --
Montana......................................................       98,708        9,260           86       16,255       34,947       17,397       19,200
Nebraska.....................................................      168,383       21,310          235       23,715       42,586       27,099       53,438
Nevada.......................................................      105,233       11,311          427       15,754       51,492       23,006        1,924
New Hampshire................................................       96,954       12,240          399       11,337       49,552       22,552          313
New Jersey...................................................      789,666       91,674        1,205      142,824      356,618      188,048          290
New Mexico...................................................      286,763       17,385          645       39,161      170,368       59,204           --
New York.....................................................    3,035,477      378,165        3,766      506,807    1,353,135      626,200      167,404
North Carolina...............................................    1,084,337      152,218        1,364      142,610      536,678      251,467           --
North Dakota.................................................       61,383       10,791           34        8,686       26,074       12,402        2,291
Ohio.........................................................    1,532,547      188,866        1,086      231,435      777,100      329,710        4,350
Oklahoma.....................................................      393,613       51,666          686       55,479      198,806       86,032          944
Oregon.......................................................      451,959       37,783        1,341       44,816      119,661       55,512           --
Pennsylvania.................................................    1,230,193      167,477          564      268,478      548,087      219,112       24,078
Rhode Island.................................................      135,230       19,294          224       25,028       60,761       29,923           --
South Carolina...............................................      495,500       77,488        1,857       92,681      234,783       86,897        1,794
South Dakota.................................................       74,077        9,380          149       13,337       38,011       13,200           --
Tennessee....................................................    1,466,194      108,325        3,063      217,635      460,778      172,713       14,475
Texas........................................................    2,561,957      307,993        4,158      266,035    1,451,316      532,455           --
Utah.........................................................      160,408        9,125          128       18,882       87,330       43,324          781
Vermont......................................................       99,693       10,327           78       14,621       50,406       21,019           --
Virginia.....................................................      681,313       85,366        1,112      104,621      363,954      126,260           --
Washington...................................................      639,256       53,111          380      104,436      316,436      163,507           60
West Virginia................................................      388,667       34,765          342       74,303      178,801       96,283        4,173
Wisconsin....................................................      460,016       65,133        1,185      103,560      127,206       79,946       80,339
Wyoming......................................................       51,374        5,924           14        6,218       27,249       10,947          587
Puerto Rico..................................................    1,054,638      180,065          444       69,129      582,038      222,962           --
Virgin Islands...............................................       17,389        1,095            7          877       10,130        4,618          662
                                                              ------------------------------------------------------------------------------------------
    United States............................................   35,209,559    3,937,789       91,168    5,696,842   16,571,536    7,375,942      629,300
    All jurisdictions........................................   36,281,586    4,118,949       91,619    5,766,848   17,163,704    7,603,522     629,962
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note.--Total recipients include unknowns which are not reflected in this table.

 Source: Health Care Financing Administration, U.S. Department of Health and Human Services.

                                 TABLE 15-16.--MEDICAID EXPENDITURES BY BASIS OF ELIGIBILITY BY STATE, FISCAL YEAR 1995
                                                                [In millions of dollars]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                            Aged, blind and      AFDC
                   State                         Total        Aged      Blind    Disabled     AFDC       AFDC      Other        disabled       children
                                             expenditures                                   children    adults   title XIX     (percent)      (percent)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama....................................       $1,455        $452        $6       $589       $194       $171        $10             71.9         13.3
Alaska.....................................          252          45         1         76         79         52  .........             48.1         31.3
Arizona....................................          218          16         1         66         75         60  .........             38.2         34.2
Arkansas...................................        1,376         387         8        662        121         79        108             76.9          8.8
California.................................       10,521       2,386       139      4,242      1,394      2,043        216             64.3         13.3
Colorado...................................        1,063         321         3        451        144        136  .........             72.9         13.5
Connecticut................................        2,125         955         4        768        229        170          0             81.3         10.8
Delaware...................................          324          76         1        148         58         38          2             69.2         17.8
District of Columbia.......................          532         132         2        251         87         60          0             72.2         16.4
Florida....................................        4,802       1,552        16      1,785      1,093        293         64             69.8         22.8
Georgia....................................        3,076         572       154      1,077        643        610          0             58.6         20.9
Hawaii.....................................          258         156         0         93          3          3  .........             97.0          1.3
Idaho......................................          360          94         0        165         52         47          1             72.1         14.5
Illinois...................................        5,600       1,068        11      2,744        958        654        165             68.3         17.1
Indiana....................................        1,878         685         6        688        309        168         16             73.4         16.5
Iowa.......................................        1,036         296         2        457        169        111          1             72.8         16.3
Kansas.....................................          831         251         1        346        135         90          0             72.0         16.2
Kentucky...................................        1,945         468         8        882        294        264  .........             69.9         15.1
Louisiana..................................        2,708         683        11      1,170        509        335  .........             68.8         18.8
Maine......................................          760         247         1        319         99         74         20             74.6         13.0
Maryland...................................        2,019         509         3        923        328        189         67             71.1         16.3
Massachusetts..............................        3,972       1,499       101      1,701        393        278  .........             83.1          9.9
Michigan...................................        3,409         796        11      1,595        451        429         10             70.5         13.2
Minnesota..................................        2,550         903        10      1,182        274        181  .........             82.1         10.8
Mississippi................................        1,266         352         6        528        232        139          7             70.0         18.3
Missouri...................................        2,039         696         5        726        374        236  .........             70.0         18.3
Montana....................................          326         107         1        130         32         30         25             73.0         13.4
Nebraska...................................          608         213         2        217         45         45         85             71.3         13.2
Nevada.....................................          350          78         3        139         59         47         18             62.7         13.0
New Hampshire..............................          473         190        10        165         68         39          0             77.2         12.8
New Jersey.................................        3,813       1,191        10      1,741        374        483          1             77.1         12.6
New Mexico.................................          714         124         6        301        182        102  .........             60.2         12.4
New York...................................       22,086       7,726       187      9,484      2,657      1,707        325             78.8         12.2
North Carolina.............................        3,175         959        11      1,034        633        538  .........             63.1         12.0
North Dakota...............................          297         121         0        119         30         22          3             80.8         11.8
Ohio.......................................        5,585       2,029         5      2,118        857        574          2             74.3         11.6
Oklahoma...................................        1,055         321         2        376        243        111          1             66.3         11.4
Oregon.....................................        1,327         270        34        499        215         79  .........             60.5         11.2
Pennsylvania...............................        4,633       1,956         2      1,759        551        323         42             80.2         11.0
Rhode Island...............................          673         273         2        302         54         42  .........             85.7         10.8
South Carolina.............................        1,438         400         7        607        262        160          2             70.5         10.6
South Dakota...............................          305         102         1        136         44         22  .........             78.4         10.4
Tennessee..................................        2,772         603        10        876        366        217        119             53.7         10.2
Texas......................................        6,565       1,841        23      2,024      1,527      1,150  .........             59.2         10.0
Utah.......................................          464          84         1        185         92         89         10             58.1          9.8
Vermont....................................          320          95         1        143         50         30  .........             74.5          9.6
Virginia...................................        1,833         566         6        722        329        210  .........             70.6          9.4
Washington.................................        1,461         508         2        562        173        214          0             73.4          9.2
West Virginia..............................        1,169         296         1        467        176        181         48             65.4          9.0
Wisconsin..................................        1,894         782         9        747         90        105        131             81.2          8.8
Wyoming....................................          171          50         0         66         29         24          1             67.8          8.6
Puerto Rico................................          244          41         0         16        135         52  .........             23.6          8.3
Virgin Islands.............................           12           3         0          2          4          4          0             36.8          8.1
                                            ------------------------------------------------------------------------------------------------------------
    United States..........................      119,885      36,483       848     48,552     17,838     13,456      1,499             71.6          7.9
    All jurisdictions......................      120,141      36,527       848     48,570     17,976     13,511      1,499             71.5         7.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
Note.--Total expenditures include unknowns which are not reflected in this table.

 Source: Health Care Financing Administration, U.S. Department of Health and Human Services.

                            TABLE 15-17.--TOTAL AND PER CAPITA MEDICAID PAYMENTS FOR CATEGORICALLY NEEDY AND MEDICALLY NEEDY, FISCAL YEARS 1975, 1981, 1992, AND 1995
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                1975                          1981                           1992                           1995                Percent change
                                                   --------------------------------------------------------------------------------------------------------------------------       1975-95
                 Category of needy                     Total    Percent              Total    Percent              Total    Percent               Total    Percent           -------------------
                                                      amount       of      Per      amount       of      Per      amount       of       Per      amount       of       Per      Total      Per
                                                    (millions)   total    capita  (millions)   total    capita  (millions)   total    capita   (millions)   total    capita   spending   capita
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Categorically needy:

  Receiving cash payments.........................     $7,188      58.7     $431    $14,534      53.4     $861    $41,742      46.0    $2,238    $53,718      44.7    $2,773     647.3     543.4
        Aged......................................      1,341      11.0      555      2,480       9.1    1,270      5,795       6.4     3,778      7,089       5.9     4,540     428.6     718.0
        Blind.....................................         61       0.5      717        109       0.4    1,527        334       0.4     4,669        464       0.4     6,745     660.2     840.7
        Disabled..................................      2,042      16.7    1,094      5,616      20.6    2,490     19,863      21.9     6,097     29,524      24.6     6,926   1,345.9     533.1
        AFDC children.............................      1,850      15.1      222      3,002      11.0      361      8,376       9.2       891      9,193       7.7     1,006     396.9     353.2
        Adults in AFDC families...................      1,895      15.5      478      3,328      12.2      769      7,374       8.1     1,682      7,448       6.2     1,715     293.0     258.8

    Not receiving cash payments...................      1,753      14.3    1,261      4,736      17.4    2,641     16,064      17.7     4,243     20,458      17.0     4,369   1,067.0     246.5
        Aged......................................      1,275      10.4    2,331      3,143      11.6    5,273      7,085       7.8    11,658      8,935       7.4    13,823     600.8     493.0
        Blind.....................................         12       0.1    1,094         19       0.1    2,785         80       0.1    15,310         70       0.1    14,167     483.3   1,195.0
        Disabled..................................        353       2.9    1,854      1,214       4.5    5,146      5,065       5.6    11,913      6,248       5.2    11,375   1,670.0     513.5
        AFDC children.............................         61       0.5      152        153       0.6      302      1,764       1.9     1,156      2,560       2.1     1,222   4,096.7     703.9
        Adults in AFDC families...................         27       0.2      144         87       0.3      298      1,428       1.6     1,606      1,720       1.4     1,679   6,270.4   1,066.0
        Other title XIX...........................         25       0.2      463        120       0.4      734        643       0.7     1,927        925       0.8     2,560   3,600.0     452.9
                                                   ---------------------------------------------------------------------------------------------------------------------------------------------
          Total...................................      8,941      73.0      495     19,270      70.8    1,032     57,807      63.7     2,577     74,176      61.7     3,084     729.6       523
                                                   =============================================================================================================================================
Medically needy:
    Aged..........................................      1,742      14.2    2,672      4,303      15.8    5,260      8,927       9.8    11,724     10,203       8.5    12,396     485.7     363.9
    Blind.........................................         20       0.2    1,472         27       0.1    3,132         71       0.1    21,865        133       0.1    35,709     565.0   2,325.9
    Disabled......................................        657       5.4    2,202      2,471       9.1    4,924      5,243       5.8    13,876      7,200       6.0    15,831     995.9     618.9
    AFDC children.................................        274       2.2      324        353       1.3      460      1,592       1.8       943      1,953       1.6     1,101     612.8     239.8
    Adults in AFDC families.......................        140       1.1      368        348       1.3      613      1,265       1.4     1,930      1,628       1.4     1,730   1,062.9     370.1
    Other title XIX...............................        467       3.8      267        433       1.6      360        268       0.3     1,844        293       0.2     2,208     -37.3     727.0
                                                   ---------------------------------------------------------------------------------------------------------------------------------------------
      Total.......................................      3,301      27.0      838      7,935      29.2    2,145     17,367      19.1     4,782     21,410      17.8     5,186     548.6     518.9
                                                   =============================================================================================================================================
      Grand total.................................     12,242     100.0      556     27,205     100.0    1,216     90,814     100.0     2,936    120,140     100.0     3,311     881.4    495.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note.--Totals may not addd due to rounding. Fiscal year 1975 ends in June; fiscal years 1981, 1992, and 1995 end in September. Total includes other coverage groups and unknowns. Other
  categories not shown in the total for 1995 are: Other coverage pre-1988, $15,475; coverage from 1988, $7,871; and medical assistance status unknown, $1,209.

 Source: Health Care Financing Administration, U.S. Department of Health and Human Services.

            TABLE 15-18.--MEDICAID RECIPIENTS AND PAYMENTS BY BASIS OF ELIGIBILITY, FISCAL YEAR 1995
----------------------------------------------------------------------------------------------------------------
                                            Amount  (in   Percent of    Recipients    Percent of    Per capita
          Basis of eligibility               millions)       total    (in thousands)     total       payments
----------------------------------------------------------------------------------------------------------------
Age 65 and over.........................         $36,527        30.4           4,119        11.4          $8,868
Blind...................................             848         0.7              92         0.3           9,256
Disabled................................          48,570        40.4           5,767        15.9           8,422
Dependent children under age 21.........          17,976          15          17,164        47.3           1,047
Adults in families with dependent
 children...............................          13,511          11           7,604          21           1,777
Other title XIX.........................           1,499         1.2             630         1.7           2,380
                                         -----------------------------------------------------------------------
    Total \1\...........................         120,140       100.0          36,282       100.0          3,311
----------------------------------------------------------------------------------------------------------------
\1\ Total expenditure and recipient data includes unknowns.

 Source: Health Care Financing Administration, U.S. Department of Health and Human Services.

                     TABLE 15-19.--MEDICAID PAYMENTS AND PER CAPITA PAYMENTS BY BASIS OF ELIGIBILITY, SELECTED FISCAL YEARS 1975-95
                                                                [In millions of dollars]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                    Fiscal year                                                  Percent
       Basis of eligibility        ------------------------------------------------------------------------------------------------------------  change
                                      1975     1981     1984      1986      1988      1989      1990      1991      1992      1994      1995     1975-95
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                     In nominal dollars
                                   ---------------------------------------------------------------------------------------------------------------------
Payments:
  Age 65 and over.................   $4,358   $9,226   $12,815   $15,097   $17,135   $18,558   $21,508   $25,453   $29,078   $33,618   $36,527     738.2
  Blind...........................       93      154       219       277       344       409       434       475       530       644       848     811.8
  Disabled........................    3,052    9,301    11,758    14,635    18,250    20,476    23,969    27,798    33,326    41,654    48,570   1,491.4
  Dependent children under age 21.    2,186    3,508     3,979     5,135     5,848     6,892     9,100    11,690    14,491    17,302    17,976     722.3
  Adults in families with
   dependent children.............    2,062    3,763     4,420     4,880     5,883     6,897     8,590    10,439    12,185    13,585    13,511     555.2
  Other...........................      492      552       700       980     1,198     1,137     1,051       973     1,032     1,243     1,499     204.7
                                   ---------------------------------------------------------------------------------------------------------------------
    Total \1\.....................   12,242   27,204    33,891    41,005    48,710    54,500    64,859    77,048    90,814   108,270   120,140     881.4
                                   =====================================================================================================================
Per capita payment:
  Age 65 and over.................    1,205    2,948     3,957     4,808     5,425     5,926     6,717     7,577     7,770     8,331     8,868     635.9
  Blind...........................      850    1,784     2,766     3,401     4,005     4,319     5,212     5,572     6,298     7,412     9,256     988.9
  Disabled........................    1,296    3,108     4,149     4,721     5,366     5,858     6,595     6,979     7,612     7,755     8,422     549.8
  Dependent children under age 21.      228      366       411       512       583       668       811       871       959     1,006     1,047     359.2
  Adults in families with
   dependent children.............      455      725       789       864     1,069     1,206     1,429     1,540     1,752     1,791     1,777     290.5
  Other title XIX.................      273      405       590       719       891       967     1,062     1,732     1,814     2,169     2,380     771.8
                                   ---------------------------------------------------------------------------------------------------------------------
    Total, per capita payment.....      556    1,238     1,569     1,821     2,126     2,318     2,568     2,725     2,936     3,089     3,311     495.5
                                   ---------------------------------------------------------------------------------------------------------------------
                                                                                  In constant 1995 dollars
                                   ---------------------------------------------------------------------------------------------------------------------
Payments:
  Age 65 and over.................   12,476   16,907    18,863    20,919    22,169    22,919    25,300    28,503    31,610    34,562    36,527     192.8
  Blind...........................      266      262       322       384       445       505       511       532       576       662       848     218.5
  Disabled........................    8,737   15,842    17,307    20,279    23,611    25,288    28,195    31,129    36,227    42,823    48,570     455.9
  Dependent children under age 21.    6,258    5,975     5,857     7,115     7,566     8,512    10,704    13,091    15,753    17,788    17,976     187.2
  Adults in families with
   dependent children.............    5,903    6,409     6,506     6,762     7,611     8,518    10,105    11,690    13,246    13,966    13,511     128.9
  Other...........................    1,408      940     1,030     1,358     1,550     1,404     1,236     1,090     1,122     1,278     1,499       6.4
                                   ---------------------------------------------------------------------------------------------------------------------
    Total \1\.....................   35,046   46,336    49,886    56,818    63,019    67,308    76,295    86,281    98,721   111,309   120,140     242.8
                                   =====================================================================================================================
Per capita payment:
  Age 65 and over.................    3,450    5,021     5,825     6,662     7,019     7,319     7,901     8,485     8,446     8,565     8,868     157.1
  Blind...........................    2,433    3,039     4,071     4,713     5,182     5,334     6,131     6,240     6,846     7,620     9,256     280.4
  Disabled........................    3,710    5,294     6,107     6,542     6,942     7,235     7,758     7,815     8,275     7,973     8,422     127.0
  Dependent children under age 21.      653      623       605       709       754       825       954       975     1,042     1,034     1,047      60.4
  Adults in families with
   dependent children.............    1,303    1,235     1,161     1,197     1,383     1,489     1,681     1,725     1,905     1,841     1,777      36.4
  Other...........................      782      690       868       996     1,153     1,194     1,249     1,940     1,972     2,230     2,380     204.5
                                   ---------------------------------------------------------------------------------------------------------------------
    Total, per capita payment.....    1,592    2,109     2,310     2,523     2,751     2,863     3,021     3,052     3,192     3,176     3,311    108.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Data includes unknowns.

 Note.--Total may not add due to rounding. Fiscal year 1975 ends in June; all other fiscal years end in September. Nominal dollars converted to constant
  dollars using CPI-U price index. Total expenditures includes other coverage groups and unknowns for fiscal year 1994.

 Source: Health Care Financing Administration, U.S. Department of Health and Human Services, and Congressional Research Service.

                              TABLE 15-20.--MEDICAID PAYMENTS BY SERVICE CATEGORY, FISCAL YEARS 1975, 1981, 1990, AND 1995
                                                         [In millions of constant 1995 dollars]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                   1975                1981                1990                1995            Average
                                                           --------------------------------------------------------------------------------    annual
                     Service category                                                                                                          percent
                                                             Amount    Percent   Amount    Percent   Amount    Percent   Amount    Percent  change 1975-
                                                                                                                                  of total       95
--------------------------------------------------------------------------------------------------------------------------------------------------------
Inpatient hospital........................................   $10,818      30.9   $13,747      29.7   $21,630      28.4   $28,841      24.0           5.3
  General.................................................     9,659      27.6    12,253      26.4    19,582      25.7    26,331      21.9           5.4
  Mental..................................................     1,159       3.3     1,494       3.2     2,016       2.6     2,511       2.1           4.2
Skilled nursing facilities................................     6,968      19.9     6,873      14.8     9,441      12.4    29,052      24.2           7.8
Intermediate care facilities..............................     6,484      18.5    12,780      27.6    20,022      26.2     (\2\)     (\1\)         (\1\)
  Intermediate care facilities for the mentally retarded..     1,088       3.1     5,103      11.0     8,651      11.3    10,383       8.6           2.5
  Other...................................................     5,396      15.4     7,677      16.6    11,371      14.9     (\2\)     (\1\)         (\1\)
Physician.................................................     3,507      10.0     3,579       7.7     4,726       6.2     7,360       6.1           4.0
Dental....................................................       970       2.8       925       2.0       698       0.9     1,019       0.8           0.3
Other practitioner........................................       364       1.0       388       0.8       438       0.6       986       0.8           5.4
Outpatient hospital.......................................     1,068       3.0     2,400       5.2     3,910       5.1     6,627       5.5          10.1
Clinic....................................................     1,114       3.2       635       1.4     1,986       2.6     4,280       3.6           7.3
Lab and x ray.............................................       361       1.0       250       0.5       848       1.1     1,180       1.0           6.4
Home health...............................................       200       0.6       729       1.6     4,004       5.2     9,406       7.8          22.5
Prescribed drugs..........................................     2,333       6.7     2,615       5.6     5,199       6.8     9,791       8.1           7.8
Family planning...........................................       192       0.5       237       0.5       312       0.4       514       0.4           5.3
Early and periodic screening..............................     (\2\)       0.0       114       0.2       233       0.3     1,169       1.0         (\1\)
Rural health clinic.......................................     (\2\)       0.0         7       0.0        40       0.1       216       0.2         (\1\)
Other.....................................................       667       1.9     1,054       2.3     2,806       3.7     9,214       7.7          14.8
                                                           ---------------------------------------------------------------------------------------------
    Total \3\.............................................    35,046     100.0    46,336     100.0    76,295     100.0   120,141     100.0          6.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Prior to fiscal year 1991, there were two categories of Medicaid nursing home care: skilled nursing facilities and intermediate nursing facilities.
    \2\ 1975 data not available.    \3\ Total includes unknowns.

 Note.--Totals may not add due to rounding. Fiscal year 1975 ends in June; all other fiscal years end in September. Spending amounts converted to
  constant dollars using the Consumer Price Index (CPI-U).

 Source: Health Care Financing Administration, U.S. Department of Health and Human Services, and Congressional Research Service.

                                  TABLE 15-21.--MEDICAID RECIPIENTS BY SERVICE CATEGORY, SELECTED FISCAL YEARS 1975-95
                                                                     [In thousands]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                Fiscal year
                Service category                 -------------------------------------------------------------------------------------------------------
                                                      1975         1981         1989         1990         1991         1992         1994         1995
--------------------------------------------------------------------------------------------------------------------------------------------------------
Inpatient hospital:
    General.....................................        3,432        3,703        4,171        4,593        5,137        5,768        5,866        5,561
    Mental......................................           67           90           90           92        5,072           77           85           84
Nursing facilities \1\..........................        1,312        1,385        1,452        1,461        1,499        1,573        1,639        1,667
Intermediate care facilities for the mentally
 retarded.......................................           69          151          148          147          146          151          159          151
Physician.......................................       15,198       14,403       15,686       17,078       19,321       21,627       24,267       23,789
Dental..........................................        3,944        5,173        4,214        4,552        5,209        5,700        6,352        6,383
Other practitioner..............................        2,673        3,582        3,555        3,873        4,282        4,711        5,409        5,528
Outpatient hospital.............................        7,437       10,018       11,344       12,370       14,137       15,120       16,567       16,712
Clinic..........................................        1,086        1,755        2,391        2,804        3,511        4,115        5,258        5,322
Laboratory & x ray..............................        4,738        3,822        7,759        8,959       10,505       11,804       13,412       13,064
Home health.....................................          343          402          609          719          813          925        1,293        1,639
Prescribed drugs................................       14,155       14,256       15,916       17,294       19,602       22,030       24,471       23,723
Family planning.................................        1,217        1,473        1,564        1,752        2,185        2,550        2,566        2,501
Early and periodic screening....................        (\2\)        1,969        2,524        2,952        3,957        4,982        6,456        6,612
Rural health clinics............................        (\2\)           81          166          224          405          743          945        1,242
Other...........................................        2,911        2,344        4,583        5,126        5,957        6,702        9,908       11,416
                                                 -------------------------------------------------------------------------------------------------------
      Unduplicated total........................       22,007       21,980       23,511       25,255       28,280       30,926       35,053      36,282
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Prior to fiscal year 1991, there were two categories of Medicaid nursing home care: skilled nursing facilities and intermediate nursing facilities.
\2\ 1975 data not available.

 Source: Health Care Financing Administration, U.S. Department of Health and Human Services.

 TABLE 15-22.--AMOUNTS OF MEDICAL VENDOR PAYMENTS BY BASIS OF ELIGIBILITY AND TYPE OF SERVICE, FISCAL YEAR 1995
----------------------------------------------------------------------------------------------------------------
                                                                           AFDC
       Type of service           Aged        Blind     Disabled  ------------------------    Other       Total
                                                                   Children     Adults     title XIX
----------------------------------------------------------------------------------------------------------------
                                                            In millions of dollars

                             -----------------------------------------------------------------------------------
Inpatient hospital services.    $2,049.8       $86.2   $11,334.9    $6,587.5    $5,544.1      $529.1   $26,131.8
Mental hospital services for
 the aged...................     1,124.1         0.2        44.7         8.3         1.1        12.8     1,191.2
SNF/ICF mental health
 services for the aged......        25.3         0.0         5.3        91.1         0.0         0.0       121.7
Inpatient psychiatric
 services, aged under 21....         0.7         0.3       487.9       587.6        13.3       162.6     1,252.3
ICF services for the
 mentally retarded..........       636.9       191.5     9,488.6        46.5         3.5         7.7    10,374.7
ICF services--all other.....     1,956.4         5.0       296.1         0.2         0.9         0.3     2,258.9
SNF services................    22,191.5       214.0     4,283.0        28.1        38.2        20.3    26,775.0
Physicians services.........       556.1        28.9     2,074.9     2,079.6     2,162.2       200.7     7,102.5
Dental services.............        61.5         1.7       180.2       547.0       201.9        23.8     1,016.0
Other practitioners services        95.8         3.5       431.7       252.8       156.2        44.7       984.7
Outpatient hospital services       534.5        25.2     2,425.9     1,862.6     1,651.8        94.5     6,594.5
Clinic services.............       258.3        30.9     2,388.7       884.9       609.0        77.6     4,249.3
Home health services........     2,806.9       124.8     5,735.2       375.5        79.0        53.1     9,174.5
Family planning services....         1.6         0.6        48.6        54.1       398.9         7.6       511.4
Lab and x-ray services......        73.0         4.0       380.2       242.1       458.4        15.6     1,173.4
Prescribed drugs............     2,861.3        69.6     4,724.7     1,116.6       939.1        63.9     9,775.3
Early and periodic screening         0.2         1.9       215.8       854.7        31.5        34.1     1,138.3
Rural health clinic services       197.3         0.5        42.3       279.3        54.3         0.7       574.3
Other care..................     1,009.2        59.0     3,974.2     2,174.1     1,167.7       150.2     8,534.4
Unknown/error...............         1.3         0.2         7.3         1.7         0.0         0.0        10.4
                             -----------------------------------------------------------------------------------
      Total.................    36,441.5       848.0    48,570.1    18,074.4    13,511.0     1,499.4   118,944.4
                             -----------------------------------------------------------------------------------

                                                                  In percent

                             -----------------------------------------------------------------------------------
Inpatient hospital services.         5.6        10.2        23.3        36.4        41.0        35.3        22.0
Mental hospital services for
 the aged...................         3.1         0.0         0.1         0.0         0.0         0.9         1.0
SNF/ICF mental health
 services for the aged......         0.1         0.0         0.0         0.5         0.0         0.0         0.1
Inpatient psychiatric
 services, aged under 21....         0.0         0.0         1.0         3.3         0.1        10.8         1.1
ICF services for the
 mentally retarded..........         1.7        22.6        19.5         0.3         0.0         0.5         8.7
ICF services--all others....         5.4         0.6         0.6         0.0         0.0         0.0         1.9
SNF services................        60.9        25.2         8.8         0.2         0.3         1.4        22.5
Physicians services.........         1.5         3.4         4.3        11.5        16.0        13.4         6.0
Dental services.............         0.2         0.2         0.4         3.0         1.5         1.6         0.9
Other practitioners services         0.3         0.4         0.9         1.4         0.0         3.0         0.8
Outpatient hospital services         1.5         3.0         5.0        10.3        12.2         6.3         5.5
Clinic services.............         0.7         3.6         4.9         4.9         4.5         5.2         3.6
Home health services........         7.7        14.7        11.8         2.1         0.6         3.5         7.7
Family planning services....         0.0         0.1         0.1         0.3         3.0         0.5         0.0
Lab and x-ray services......         0.2         0.5         0.8         1.3         3.4         1.0         1.0
Prescribed drugs............         7.9         8.2         9.7         6.2         7.0         4.3         8.2
Early and periodic screening         0.0         0.2         0.4         4.7         0.2         2.3         1.0
Rural health clinic services         0.5         0.1         0.1         1.5         0.4         0.0         0.5
Other care..................         2.8         7.0         8.2        12.0         8.6        10.0         7.2
Unknown/error...............         0.0         0.0         0.0         0.0         0.0         0.0         0.0
                             -----------------------------------------------------------------------------------
      Total.................       100.0       100.0       100.0       100.0       100.0       100.0      100.0
----------------------------------------------------------------------------------------------------------------
Source: Health Care Financing Administration, U.S. Department of Health and Human Services.

       TABLE 15-23.--AVERAGE EXPENDITURE PER RECIPIENT BY BASIS OF ELIGIBILITY BY STATE, FISCAL YEAR 1995
----------------------------------------------------------------------------------------------------------------
                                                                                           AFDC           Other
                   State                      Total     Aged      Blind   Disabled --------------------   title
                                                                                    Children   Adults      XIX
----------------------------------------------------------------------------------------------------------------
Alabama...................................    $2,698    $6,339    $3,795    $4,534      $794    $1,920    $3,372
Alaska....................................     3,698    10,056     7,571    11,500     2,033     2,849         -
Arizona...................................       442       656     1,449     1,087       251       542         -
Arkansas..................................     3,893     7,361     6,433     7,684     1,014     1,355     3,403
California................................     2,097     4,906     5,425     5,919       634     1,484     2,310

Colorado..................................     3,619     8,714    27,940     9,131     1,120     1,883         -
Connecticut...............................     5,588    14,373    13,890    15,512     1,286     1,966       449
Delaware..................................     4,128    12,472     7,613    11,778     1,348     2,384     3,441
District of Columbia......................     3,843    16,439     9,062    10,572     1,195     1,814       777
Florida...................................     2,768     7,325     4,974     6,548     1,096     1,401     1,534

Georgia...................................     2,681     5,500    10,998     6,070     1,076     2,498     3,398
Hawaii....................................     4,983     9,002     6,215     6,837       300       416         -
Idaho.....................................     3,129    10,040     8,239     8,975       846     1,889     2,129
Illinois..................................     3,608     8,399     8,181     9,955     1,254     1,972     3,148
Indiana...................................     3,359    10,389     5,578    10,353     1,038     1,532     1,714

Iowa......................................     3,406     7,794     4,496     9,220     1,209     1,499       959
Kansas....................................     3,250     9,768     6,387     8,856     1,045     1,620       213
Kentucky..................................     3,035     7,408     4,597     5,711     1,089     2,094         -
Louisiana.................................     3,449     6,665     6,584     7,384     1,354     2,286         -
Maine.....................................     4,965    12,738     6,486    10,043     1,502     2,349     4,966

Maryland..................................     4,873    10,615     8,941    10,816     1,668     2,565     6,589
Massachusetts.............................     5,460    14,483    14,740    11,069     1,264     1,824         -
Michigan..................................     2,918     9,245     5,348     7,223       831     1,426     3,259
Minnesota.................................     5,386    14,311    15,901    15,765     1,172     1,799         -
Mississippi...............................     2,436     5,277     3,645     4,251       938     1,826     3,424

Missouri..................................     2,932     7,492     4,836     7,518     1,075     1,516         -
Montana...................................     3,300    11,546     6,631     8,009       916     1,732     1,307
Nebraska..................................     3,609    10,019     8,831     9,171     1,063     1,652     1,584
Nevada....................................     3,322     6,863     6,803     8,806     1,145     2,048     9,405
New Hampshire.............................     4,880    15,559    24,356    14,570     1,377     1,735       531

New Jersey................................     4,828    12,988     8,237    12,188     1,049     2,567     2,581
New Mexico................................     2,491     7,110     8,608     7,685     1,067     1,730         -
New York..................................     7,276    20,431    49,636    18,713     1,964     2,727     1,939
North Carolina............................     2,928     6,301     8,281     7,251     1,179     2,139         -
North Dakota..............................     4,839    11,176     5,837    13,713     1,156     1,805     1,487

Ohio......................................     3,644    10,742     5,042     9,152     1,103     1,742       350
Oklahoma..................................     2,680     6,217     3,291     6,781     1,225     1,288       934
Oregon....................................     2,937     7,149    25,375    11,140     1,798     1,418         -
Pennsylvania..............................     3,766    11,679     4,113     6,553     1,006     1,473     1,752
Rhode Island..............................     4,973    14,155     8,095    12,053       882     1,416         -

South Carolina............................     2,902     5,157     3,979     6,552     1,118     1,840       884
South Dakota..............................     4,120    10,926     5,645    10,192     1,164     1,645         -
Tennessee.................................     1,891     5,567     3,108     4,024       793     1,256     8,195
Texas.....................................     2,562     5,978     5,491     7,608     1,052     2,160         -
Utah......................................     2,895     9,240     6,122     9,792     1,058     2,064    13,209

Vermont...................................     3,210     9,160     6,741     9,801       999     1,448         -
Virginia..................................     2,690     6,627     5,356     6,901       904     1,662         -
Washington................................     2,285     9,572     4,428     5,384       547     1,308     4,278
West Virginia.............................     3,009     8,517     4,252     6,283       985     1,876    11,571
Wisconsin.................................     4,118    12,010     7,413     7,215       704     1,307     1,630

Wyoming...................................     3,328     8,389     1,606    10,648     1,067     2,225     2,014
Puerto Rico...............................       232       229       685       234       232       232         -
Virgin Islands............................       670     2,453     3,190     1,803       355       772       295
                                           ---------------------------------------------------------------------
    United States.........................     3,405     9,265     9,298     8,523     1,076     1,824     2,382
    All jurisdictions.....................     3,311     8,868     9,256     8,422     1,047     1,777    2,380
----------------------------------------------------------------------------------------------------------------
Source: Health Care Financing Administration, U.S. Department of Health and Human Services.

    TABLE 15-24.--OPTIONAL MEDICAID SERVICES AND NUMBER OF STATES \1\
                   OFFERING EACH SERVICE, OCTOBER 1996
------------------------------------------------------------------------
                                                   States
                                    States        offering     Access to
                                   offering     services to     include
            Service              services to        both       Medicaid
                                categorically  categorically   services
                                  needy only   and medically    to the
                                                   needy       uninsured
------------------------------------------------------------------------
Podiatrists' services.........             9             27           10
Optometrists' services........            11             28           10
Chiropractors' services.......             4             20            4
Psychologists' services.......             6             20            6
Medical social workers'
 services.....................             1              6            3
Nurse anesthetists' services..             8             16            5
Private duty nursing..........             4             16            6
Clinic services...............            13             33            9
Dental services...............            11             26            9
Physical therapy..............            10             29            6
Occupational therapy..........             6             24            6
Speech, hearing and language
 disorder.....................            11             26            5
Prescribed drugs..............            14             32           10
Dentures......................             7             25            6
Prosthetic devices............            14             31           10
Eyeglasses....................            12             27            9
Diagnostic services...........             5             22            7
Screening services............             5             20            7
Preventive services...........             6             20            6
Rehabilitative services.......            13             31            9
Services for age 65 and older
 in mental institutions:
    A. Inpatient hospital
     services.................            12             21            9
    B. SNF services...........             9             17            6
    C. ICF/MR services........            18             22           10
Inpatient psychiatric services            12             21            9
Christian science nurses......             1              2            1
Christian science sanitoria...             3              7            4
SNF for under age 21..........            16             26           10
Emergency hospital services...            11             25            8
Personal care services........             7             18            6
Transportation services.......            13             32           10
Case management services......            11             27            8
Hospice services..............             8             22            8
Respiratory care services.....             2              9            3
TB related services...........             1              5           3
------------------------------------------------------------------------
\1\ Includes the territories.

 Source: Health Care Financing Administration, U.S. Department of Health
  and Human Services.
---------------------------------------------------------------------------

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