The Limits of Medicaid Reform in Pennsylvania COMMONWEALTH, Volume 18, Issue 2 (2016). © 2016 The Pennsylvania Political Science Association. ISSN 2469-7672 (online). http://dx.doi.org/10.15367/cjppp.v18i2.112. All rights reserved. The Limits of Medicaid Reform in Pennsylvania Thinking Regionally about Access to Insurance and Health Care under the Affordable Care Act MICHELE MOSER DEEGAN Muhlenberg College A. LANETHEA MATHEWS- SCHULTZ Muhlenberg College States’ varied decisions with respect to Medicaid expansion under the Afford- able Care Act have drawn significant attention to questions about equity across states. Missing from the conversation is consideration of the varied impact that reform will have within states. This article considers how low- income Pennsyl- vanians will fare under Medicaid expansion. Although Medicaid reform has already expanded access to insurance to significant numbers of low- income residents in the state, improvements in access to health care are mediated by pre- existing regional inequalities in social determinants of health and by Penn- sylvania’s system of health governance. Drawing on lessons gleaned from the literature on regionalism, and examples of success in states that have adopted regional approaches to health delivery, we offer a theoretical approach for thinking regionally in Pennsylvania by building opportunities and capacities for cross- jurisdictional approaches to health and health care access. The Patient Protection and Affordable Care Act (Public Law 111–148 [123 Stat. 119 (2010)] [ACA]), is designed to make the health care sys- tem more effective and efficient, while expanding insurance coverage and preventative care to millions of Americans. The ACA alters the existing health care system by expanding the regulatory role of the federal and state 4 Michele Moser Deegan anD a. lanethea Mathews- schultz governments and by requiring insurers and health care providers to restruc- ture their personnel and services to accommodate the requirements of the law. Not only is “Obamacare” the most significant health care overhaul since 1965, when Medicaid and Medicare were instituted, but the ACA also provides a unique window for examining the politics of implementation of federal policy reform across a diverse and fragmented nation. Extending Medicaid to uninsured low- income citizens is a key mechanism of the ACA. As originally conceived, starting in 2014, an expanded Medicaid extends coverage to all individuals under 65 years of age with incomes up to 138% of the federal poverty level (Kenney et al. 2012).1 The federal government is picking up 100% of the costs of new enrollees initially, reducing its contri- butions to these costs to 95% in 2016, and to 90% in 2020. The original ACA required states to expand Medicaid under threat of loss of all federal Medicaid reimbursements for existing enrollees.2 In National Federation of Independent Business et al. v Sebelius, Secretary of Health and Human Services, et al. (2012), however, the Supreme Court held that, because Congress’s tax and spend pow- ers do not extend to compel the states to enact or administer federal regula- tory programs, the mandated Medicaid expansion was unconstitutional. The Court’s decision, in short, made Medicaid expansion, and therefore also full implementation of the ACA, a matter of state choice. States’ varied decisions with respect to Medicaid expansion have drawn significant attention to questions about equity across states (for example, Jacobs and Callaghan 2013). To be sure, since Medicaid’s inception in 1965, states have been required to comply with federal criteria—determining, for example, who receives care and what funds are provided at what costs—as a condition of receiving federal Medicaid funds. However, eligibility require- ments, scope and breadth of services and benefits, and share of Medicaid funding provided by the federal government vary widely across states. As of June 2015, 30 states (including DC) have opted into adopting the ACA Medic- aid expansion, 19 have opted out, and 2 remain undetermined (Kaiser Com- mission 2012). Medicaid reform is a divisive issue; all of the states opting out are Republican- led (although 10 states had Republican governors when they decided to expand) and no states in the Deep South are expanding, making Medicaid reform regionally concentrated. Missing from the national conversation about ACA outcomes is consid- eration of the varied impact that reform will have within states. States have diverse systems of health governance that are not inconsequential to health outcomes. This is especially true for low- income residents who face the greatest obstacles not simply to obtaining health insurance, but to accessing preventive The Limits of Medicaid Reform in Pennsylvania 5 care, clinical care, and other health services. In this context, Pennsylvania is uniquely situated for two reasons. First, it is one of only a handful of states that has a mixed, or hybrid, health governance structure the consequences of which remain uncertain alongside ACA reforms.3 Second, Pennsylvania’s eligibility requirements for Medicaid prior to Obamacare were among the most restrictive in the nation, positioning the state to exponentially expand Medicaid enrollees and thereby significantly alter the landscape of health within its borders. The state of Pennsylvania has a vested interest in improv- ing health for Medicaid enrollees, as they accounted for close to a quarter of the state’s population prior to Obamacare. Politically speaking, Pennsylvania is also somewhat unusual, having first opted out of the federal expansion in favor of a state- run demonstration project, only to quickly reverse course a few months later following a change in control of the governor’s office. How will low- income Pennsylvanians fare under ACA Medicaid reform? It is certain that hundreds of thousands of previously uninsured residents will gain health insurance, but consequences for health care and health out- comes among the population are less clear. In this article, we take stock of Medicaid reform in Pennsylvania with three goals in mind. First, after a brief historical review of the political context behind the state’s labored decision to expand Medicaid, we provide a sketch of reform outcomes to date, focus- ing on low- income residents’ access to health insurance. Health insurance is a precursor to, not the equivalent of health. Therefore, our second goal is to explicate barriers to health among low- income Pennsylvanians—barriers that include geographical variation in access points to primary health care. Where low- income residents can access health is determined in part by social and economic conditions of unemployment, poverty, transportation, and housing. It is also determined by the structure of health governance within the state and it is this latter variable that holds our primary interest. Not only does the ACA largely sidestep these interdependent determinants of health inequality, but by centralizing the administration of health, the governance structure of Pennsylvania state health may exacerbate health inequalities. Thus, our third goal is to suggest a theoretical framework for approaching health regionally in Pennsylvania, one that is open to reforming administrative structures of health governance to focus on regional, cross- jurisdictional approaches to public health and health care access. Absent more comprehensive reform of the state’s public health system that considers regional variation in the con- ditions that facilitate health, Medicaid reform will provide access to health insurance but, by itself, not necessarily better health outcomes for low- income Pennsylvanians. 6 Michele Moser Deegan anD a. lanethea Mathews- schultz Political Prelude One of the 26 states party to National Federation of Independent Businesses v Sebelius, Pennsylvania initially declined to participate in the federal Medicaid expansion. Following a delayed response to the Court decision, Pennsylva- nia Republican governor Tom Corbett led his administration in developing a state- run alternative to the federal expansion to pay private insurers to cover the uninsured using newly available Medicaid funds.4 After negotiating for over a year with the Obama administration, the Centers for Medicare and Medicaid Services (CMS) granted Pennsylvania a federal waiver in August 2014, enabling the Corbett administration to modify the state’s existing Med- icaid program to expand access to health insurance to adults with incomes up to 133% of the federal poverty level. Corbett’s plan, Healthy Pennsylva- nia, could enroll up to 600,000 new citizens for health care coverage begin- ning January 1, 2015. Healthy Pennsylvania had two core components. First, it modified the state’s existing Medicaid program through changed benefit plans, implementation of cost- sharing premiums, and establishment of incen- tives to encourage healthy behaviors. Second, adults previously ineligible for Medicaid but newly eligible under the ACA’s expanded requirements could gain access to health insurance through private managed health plans, or Pri- vate Care Option service delivery systems.5 Among the most controversial of these changes were cost- sharing stip- ulations and eligibility requirements linking health insurance access to “employment related activities.” The demonstration project approved by CMS permitted the state to charge monthly premiums for individuals with incomes up to 100% FPL during year two not to exceed 2% of household income (dur- ing the first year of the demonstration, no premiums were charged). Indi- viduals with incomes below 100% FPL could also be charged copayments in some circumstances. After year one of the demonstration project, individu- als could reduce their cost sharing responsibilities by demonstrating healthy behaviors—including, for example, annual wellness exams and an established record of timely copayments.6 In its original formulation, Healthy Pennsyl- vania linked health insurance eligibility for able- bodied adults, ages 21–64, working fewer than 20 hours per week to proof of engagement in “employ- ment related activities,” such as job training. Political contingencies eventu- ally forced Corbett to weaken these conditions, such that the CMS waiver stipulated that “health coverage provided by the Medicaid program and this demonstration will not be affected by” the state’s efforts to encourage employment through incentives to join training and work related activities.7 Early in his administration, Corbett criticized the ACA as “federal over- reach” and referred to Medicaid as a “broken system,” arguing “it would The Limits of Medicaid Reform in Pennsylvania 7 be financially unsustainable for the taxpayers,” to participate in the federal expansion (Beeler 2013). At the same time, however, like many governors, Corbett faced political and budgetary pressures alongside large populations of low-i ncome residents lacking health insurance. Indeed, the Corbett Admin- istration previously eliminated adultBasic, which had provided health insur- ance for low-i ncome working adults ineligible for Medicaid, generating even greater need for affordable accessible health insurance. Corbett’s “private option” allowed the state to capitalize on additional federal funding without compromising conservative principles. One jour- nalist referred to this approach, shared by Arkansas, Iowa, and Michigan, as “making Medicaid more Republican” (Ramsay 2015). Corbett claimed a political victory in securing “a plan that was created in Pennsylvania for Pennsylvania—a plan that would allow us to reform a financially unsustain- able Medicaid program and increase access to health care for eligible individ- uals through the private market,” (in Wenner 2014) but the political realities were more complicated. The CMS demonstration waiver imposed consider- able restrictions on Healthy Pennsylvania, and ultimately, the state nudged its way toward expanding Medicaid with the help of federal funds. Corbett’s Healthy Pennsylvania was criticized both within and outside of the state and its brief life was both cause and consequence of the electoral poli- tics of the 2014 gubernatorial elections. The second half of Corbett’s first term saw declining public approval ratings (University of Virginia’s Larry Sabato characterized Corbett “the incumbent Republican governor most likely to lose in 2014” [in LaRosa 2013]). Corbett’s Administration was flanked by seem- ingly endless bad news: drastic education cuts, teacher layoffs, controversial abortion legislation, poor job growth. His administration was also troubled by fallout from his own verbal gaffes and relative weak likeability compared to the Democratic challenger, Tom Wolf. One of the most watched gubernatorial elections of 2014, the Corbett campaign was heavily funded by the Republi- can Governors’ Association; Wolf, CEO of a family-owned building materials business and former state revenue secretary, donated $10 million to his own campaign and received support of major labor and teachers’ unions in the state. Campaigning with a promise to revoke Healthy Pennsylvania in favor of expanding the state’s preexisting Medicaid program with support from ACA federal funds, Wolf secured victory with 55% of the vote. In what was characterized as an otherwise Republican friendly midterm election, Corbett became the first incumbent governor in Pennsylvania not elected to a second term (Olson and Esack 2014). Despite his loss in November 2014, Corbett’s administration began imple- mentation of Healthy Pennsylvania in January 2015. At the time of Wolf ’s 8 Michele Moser Deegan anD a. lanethea Mathews- schultz inauguration that February, approximately 120,000 Pennsylvanians had already enrolled. True to his campaign promises, Wolf began transitioning the state away from the waiver program in early Spring 2015, toward tradi- tional ACA Medicaid. With an intended completion timeline of September 2015, Wolf announced that all individuals enrolled in Healthy Pennsylvania or eligible for Medicaid would be moved into the state’s pre- existing Medicaid managed- care plan, HealthChoices. Wolf reinstated benefit packages previ- ously modified by the Corbett administration, while cost- sharing premiums and healthy behavior incentives—core components in Corbett’s original state demonstration project—were eliminated. Medicaid Expansion in Pennsylvania Perhaps the most significant anticipated effects of Medicaid reform in Penn- sylvania (and elsewhere) will result from the expansion of coverage to pre- viously uninsured and ineligible poor adults without dependent children (“childless adults” or “other adults”).8 Medicaid reform will also enroll more working parents, previously ineligible under restrictive state requirements. According to the Kaiser Commission, before the ACA, 33 states limited eligi- bility for working parents below 100% of the federal poverty level (FPL)—in 16 of those states, including Pennsylvania, eligibility was restricted to parents earning less than 50% of the FPL. Working parents with dependent children in Pennsylvania were eligible for Medicaid with incomes up to 99% of the federal poverty level; nondisabled adults without children were not eligible for Medicaid at all.9 Eligibility in Pennsylvania now includes all adults, ages 21–64, with incomes up to 138% of the federal poverty level, equal to approxi- mately $21,984 for a family of two in 2015. What does Medicaid enrollment expansion in Pennsylvania look like so far? In 2014, Medicaid provided coverage for approximately 2.2 million Penn- sylvanians, including approximately 1.1 million adults and 1.1 million children. At the start of 2015, state officials estimated that 600,000 additional residents would be eligible for health insurance under an expanded program. Between January and July 2015, the state’s Medicaid program, HealthChoices, added 440,000 new enrollees (including the approximately 120,000 residents who had been enrolled in Corbett’s short- lived state- run alternative).10 As seen in Figure 1, total Medicaid enrollment in Pennsylvania grew to more than 2.5 million by July 2015. Among adults, Medicaid enrollments increased by 18% within one year, jumping from 1,137,635 in June 2014 to 1,391,534 in June 2015. Appendix A and Figure 2 contain additional information about Medicaid enrollment both before and after the ACA expansion by county. Appendix A The Limits of Medicaid Reform in Pennsylvania 9 also provides the best available information about the population of each county most likely to benefit from new Medicaid requirements—adults living at or below 139% of the federal poverty level just before the Medicaid expan- sion took effect.11 Close to 1.4 million adults ages 18–64 were living under 139% FPL in 2013 across the state, and approximately 400,000 of those were Note: “Adult” in this figure refers to individuals ages 21 to 64. Figure 1. Statewide Total and Adult Medicaid Enrollment, April 2014 to July 2015. (Pennsylvania Department of Human Services.) Figure 2. Percentage Change in Medicaid Enrollment ages 18–64 from 2014 to 2015. (U.S. Census Bureau, American Community Survey, 2008–2013; Pennsylvania Department of Health; and Pennsylvania Association of Community Health Centers, Community Health Center Directory, 2015.) 10 Michele Moser Deegan anD a. lanethea Mathews- schultz uninsured. As is to be expected, the most populous counties in the state report the highest real numbers of poor uninsured adults, including most notably Allegheny and Philadelphia Counties. But, counties vary in the proportion of poor uninsured adults relative to overall county populations. For example, Pike County is a relatively small county with an overall population of 56,414 and a small population of poor adults, 5,000 individuals. Close to 37% of Pike County’s poor adults are uninsured, however, exceeding the statewide average by more than 8 percentage points. Pennsylvania tracks and records total Medicaid enrollments by county each month, but unfortunately, the state does not report the numbers of enrollees newly eligible after 2015. Thus, monthly enrollment figures include previously enrolled Medicaid recipients in addition to newly enrolled.12 While the data reported in Appendix A and Figure 2 are not perfect, they provide a partial window into changes at the county level and statewide variation as a result of Medicaid expansion. The state as a whole experienced an almost 19% increase in adult Medicaid enrollment between June 2014 and June 2015. Increases within the counties range from a high of 28% in Pike County to a low of 12% in Montour County. In Pike, as in other darker shaded coun- ties in the east and southeastern regions, Medicaid enrollment increased from 2014–2015. Most of the counties with higher percentages of Medicaid enrollees are those with a higher percentage of previously uninsured, sug- gesting that Medicaid expansion is having the intended effect of expanding insurance to many poor individuals. Because we say more about the Lehigh Valley region of Pennsylvania below, it’s worth noting Medicaid expansion in this region. Combined, Lehigh and Northampton Counties include about 630,000 residents and about 61,000 of these are adults living in poverty. In 2013, 19,737 adults living in poverty in this region lacked health insurance. Lehigh County experienced a 22% increase in Medicaid enrollments since 2015; in Northampton, the increase has been about 24%. While these num- bers are encouraging, as we explore further below, access to insurance is no guarantee of improved access to health care, particularly in a context defined by intra- state and inter- regional inequalities in both social determinants of health and availability of access points to care. Thinking beyond Insurance: Health Governance and Regional Health Care Inequality States’ pre- ACA structures and processes for administering Medicaid and other health related programs provide a critical context for considering imple- mentation of Medicaid reform under Obamacare. Indeed, the contours of The Limits of Medicaid Reform in Pennsylvania 11 Medicaid prior to the ACA were in many ways the result of states’ interests and financial incentives, which collectively helped propel the program’s evolution, decoupling it from welfare and relaxing eligibility rules in the 1980s (lead- ing to exponential increase in enrollment) and transitioning (in a majority of states) to managed care plans in an effort to reduce costs in the 1990s. In 2010, Medicaid expansion was the most politically palatable option for expanding health insurance coverage not only because it is less costly than other options, but also because it is a state- administered program (Brecher and Rose 2013). The state of Pennsylvania’s decision to adopt federal Medicaid reform is likely the result of both shifting political fortunes (most notably a radical ideological change in the state executive office coupled with public opinion and pressure from health providers and insurers) and financial incentives (the state Depart- ment of Health estimates that cost savings will exceed $626 million in the first year and more than $645 million in the second year alone). The potential of Medicaid expansion to succeed in increasing access to insurance and to health care for low-i ncome Pennsylvanians will be shaped in part by the structure of health governance and the relationships between state and local governments. The states’ Medicaid program, HealthChoices (previously Medical Assistance) is administered through the office of Medical Assistance Programs, an office within the state Department of Human Ser- vices. Eligibility and program requirements are administered through county assistance offices. Medicaid recipients are enrolled in one of several managed care organizations (MCOs) in the state, operating throughout five “zones” within the state. Although the Department of Human Services administers Medicaid through its Office of Medical Assistance Programs, the Department of Health coordinates health resources in the state. Pennsylvania is one of just a handful of states in the nation characterized by a “hybrid” governmental model, that is, it contains both independent local health agencies and state-run health offices (Salinsky 2010).13 Public health programs are overseen by the Bureau of Community Health Systems (BCHS) in a complex network of district offices and state health centers organized into six health districts. As shown in Figure 2, the state operates health centers in 61 of Pennsylvania’s 67 counties. These are directly funded by the state and managed by state employees. State health centers provide health screenings, diagnoses and clinics to prevent commu- nicable diseases, immunizations, chronic disease prevention, health and envi- ronmental education programs, and counseling. In addition to state-funded health centers, Pennsylvania’s network of pub- lic health includes six county health departments in Erie, Allegheny, Chester, Bucks, Montgomery, and Philadelphia Counties and four local health bureaus 12 Michele Moser Deegan anD a. lanethea Mathews- schultz in the municipalities of York, Wilkes- Barre, Bethlehem, and Allentown. County Health Departments and Municipal Health Bureaus are creations of Pennsylvania Act 315, the Local Health Administration Law, which allows (but does not require nor incentivize) local governments to create their own localized departments in return for greater control over decisions about avail- able services and community partner collaborations. County Health Depart- ments and Municipal Health Bureaus are accountable for meeting state and federal public health provisions; they receive state funding but can also raise revenues through local taxation, service fees, and external grants. Staffed by local government employees, County Health Departments and Munici- pal Health Bureaus typically offer expanded public health services and work closely with community health providers. Prior to Obamacare, County Health Departments and Municipal Health Bureaus proved especially important for providing preventive services and primary care to individuals ineligible for Medicaid, and for providing services insufficiently covered by private provid- ers. For example, the Bethlehem Health Bureau provides free individual and group counseling on weight loss, diabetes, hypertension, high cholesterol, and smoking cessation for residents of Bethlehem. Similarly, the Allentown Health Bureau is part of a community wide effort, Healthy Kids Healthy Allentown, which promotes good nutrition and physical activity programs for children under 18 years of age. Of course, government organizations are not the only entities in public health. Private and nonprofit organizations are critical partners in the deliv- ery of health care and the extension of services to low- income populations. Most significant for our purposes, community health centers, including those designated as Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), are a primary source of care and preventive services for Medicaid enrollees and the uninsured and, with increased federal fund- ing provided through the ACA, will continue to serve as a significant source of primary care for low-i ncome populations. FQHCs and RCHs are nonprofit organizations, supported by federal and state funds that provide preventive primary health services under section 330 of the Public Health Service Act. They may provide services such as primary medical, dental, and behavioral health care regardless of a patient’s ability to pay. As shown in Figure 2, there are currently over 260 sites in Pennsylvania located in 45 of Pennsylvania’s 67 counties, serving approximately 700,000 individuals (Community Health Centers, 2015). In addition to these organizations, there has been an increase in the number of private care centers, such as Patient First, as well as drop- in care centers run by area hospitals. While the apparent influx of new enti- ties is encouraging, in most cases, this patchwork health care delivery system The Limits of Medicaid Reform in Pennsylvania 13 continues to lack comprehensive coverage for hospitalization, long- term care, and emergency care as well as dental care, eye and vision care, and mental health services. Likewise, little is known about the extent to which private- sector health clinics are helping to fill delivery gaps, especially for the Med- icaid population. In the best case scenario, Pennsylvanians still lacking health insurance or without easy access to primary care through a private provider can receive primary care through FQHCs or a similar organization, reducing the risk and prevalence of preventable diseases, which in turn will reduce the cost of care as individuals will be treated earlier and require less hospitalization. However, this assumes that FQHCs, or their equivalent, are located in areas accessible to these individuals. Returning to Figure 2, most FQHCs and RHCs are concentrated in the urban core of Philadelphia and in far western Pennsyl- vania, even though there have been larger increases in Medicaid enrollment in south- central and northeastern counties. Figure 3 provides complementary information about the geographic distribution of the ratio of the population to primary care physicians using the Robert Wood Johnson Foundation’s County Health Rankings and Roadmap data (www.countyhealthrankings.org). These Figure 3. Primary Care Physician Ratio by County. (Robert Wood Johnson Foundation County Health Rankings and Ratings; Pennsylvania Department of Health; and Pennsylvania Association of Community Health Centers.) 14 Michele Moser Deegan anD a. lanethea Mathews- schultz data include primary care physicians specializing in medicine, family med- icine, internal medicine, or pediatrics and provide a measure of the avail- ability of health care and access to providers. As shown, many counties with higher ratios of population to primary care physicians (those shaded darker on Figure 3), also have few if any FQHC/RHCs, potentially forcing residents to forgo preventive care, or to seek out hospital emergency rooms for non- emergent care. Comparing Figures 2 and 3 further emphasizes the need to consider more access to preventative health care for low-i ncome residents. For example, counties such as Pike, Perry, Monroe, and Bedford, which lack a sufficient number of physicians to serve the overall county population, also lack federally assisted health centers for low-i ncome residents and have seen higher increases in Medicaid enrollment. Clearly, there is a need to consider a better way to organize health services for low- income individuals living in these regions. While these figures suggest that the state’s hybrid system of health gov- ernance promotes horizontal equity in some respects—nearly every county has a state-run health center, for example—it is clear that there is consider- able variation in the extent of need among low-i ncome residents across coun- ties and in structural and environmental factors across the state. In short, low- income Pennsylvanians faced varied access to primary health care. As suggested above, the increase in insured adults as a result of Medicaid expan- sion could lead to greater health inequality, as those lacking access to health services, due to a limited number of physicians or facilities, maintain their current level of health while those living in areas with more options for health care have greater access. Additionally, previously insured individuals may face difficulties scheduling health care visits due to the increase in demand and limited supply of health care workers. The remainder of our article suggests a theoretical way of thinking region- ally to derive the greatest benefit from the ACA’s twin promise of improving health insurance and health care for low- income Americans. Seeking Regional Solutions to Health Challenges in Pennsylvania The ultimate success of the ACA will depend in large part on the willingness and ability of states, health insurers, and health care providers to transform the existing health care system. Because federally designed Medicaid reform relies on states to run and implement the expansion, it is inherently linked to a preexisting landscape of health inequalities, socioeconomic disparities, inequalities in the social determinants of health, and varied obstacles to care. The Limits of Medicaid Reform in Pennsylvania 15 In this context, location matters, as health is shaped by many factors that lie outside the boundaries of health care, including access to employment opportunities, adequate transportation, environmental issues such as air and water quality, and racial equity. Literature in the field of regionalism, for example, suggests that neighborhood access to healthy food, concentrations of poverty within geographic regions, and resource disparities within larger regional contexts are all factors that affect health outcomes at both individual and community levels (e.g., Hutson et al. 2012; Lynch et al. 1998). Moreover, individuals rely on their local communities for health care; therefore, mea- surement of the ACA’s success must include consideration of the equity, acces- sibility, and affordability of services within more localized areas. A regional boundary is defined by where people reside, travel, work, shop, and play (Hamilton 2014; Miller 2002). The recognition that municipalities within a region are interdependent is now commonplace within research and practitioner communities (Dreier et al. 2004; Hamilton 2014; Ledebur and Barnes, 1993; Orefield 2002; Pastor et al., 2000; Rusk 2003; Savitch et al. 1993; Savitch and Vogel 2000; Swanstrom et al. 2002). While there is debate about the extent and direction of this interdependency, a regional perspective is critical for understanding social disparities and economic growth at the local govern- ment level. Regions present unique governing challenges because they typically include multiple local governments and often lack static legal boundaries. The subject of health equity itself is well traversed—scholars and practi- tioners have long drawn attention to issues related to population health: racial and ethnic disparities in health and health care, state and local policy efforts to alleviate health disparities; the interconnectedness of residential segrega- tion, lack of access to health care, environmental stressors (such as violence), and community infrastructure (e.g., Institute of Medicine 2011; Kirby and Kaneda 2005; Lynch et al. 1998; Schulz et al. 2002). These findings are increas- ingly considered in the context of regionalism; indeed a recent Policy Link report suggests, “much of the innovative work around health and regional equity is occurring at the intersection between health and other areas such as transportation, housing, and economic opportunity” (2002, 23). Past research has linked race- based residential segregation and socioeconomic status to the social and material resources that promote health and limit disease (Schulz et al. 2002). Most critically for our purposes, studies of healthcare utilization suggest that an individual’s decision to access primary health care services depends upon spatial considerations, including regional availability and regional acces- sibility and aspatial factors such as income, race, ethnicity, education level, or sex (Wang and Luo 2005). Of particular importance, researchers estimate that 16 Michele Moser Deegan anD a. lanethea Mathews- schultz individuals are more likely to access services within a 15- mile radius or not exceeding a 30- minute barrier (e.g., Luo 2004; Wang and Minor 2002). While Medicaid expansion has already significantly expanded access to health insurance for more than 400,000 low- income Pennsylvanians, far sur- passing the numbers of individuals who have enrolled in individual insur- ance plans through the federal marketplace, our concern is the next step, how to ensure access to preventive and primary care for low- income individu- als with or without health insurance. Translating gains in health insurance into healthier residents and greater health equity across the state will require coordinated regional strategies. These strategies include changing state health governance structures to establish a more decentralized public health system, one that allows for regionalized implementation and state support for new collaborative regional health care systems. For example, recent research suggests that centralized, state- run health governance systems—such as the system characterizing health governance in Pennsylvania—are associated with the lowest health outcome measures on several dimensions of health, including adult smoking, low birth weight, teen births, and preventative screenings for breast cancer and diabetes (Hays et al. 2014). One of the benefits of the U.S. system of federalism is the ability to learn from state- level variation in public health delivery systems. Here, we briefly draw on Minnesota and Massachusetts, two states consistently ranked among the healthiest in the nation by the United Healthcare Foundation and Asso- ciation of State and Territorial Health Officials. Like Pennsylvania, both states have histories rooted in strong local governance. Unlike Pennsylvania, both Minnesota and Massachusetts have integrated regional approaches to public health through statewide planning that emphasizes devolving accountability and health delivery planning to local governments with state-level oversight and support. Regional Public Health in Minnesota In Minnesota, the Community Health Services system has been in place since 1976, when the state passed the Community Health Services Act (Minn. Stat. § 145A), now called the Local Public Health Act. Unlike Pennsylvania’s Act 315, which permits, but does not require, counties and municipalities to cre- ate health departments, the state of Minnesota designates Community Health Boards (CHBs) as the legal governing authorities for local public health. CHBs can be multi- county, single- county, or city- based but must serve a mini- mum population equal to 30,000 people (Minnesota Department of Health 2016). CHBs are better positioned to tailor health services to fit the needs of mailto:Minn.States.@154A mailto:Minn.States.@154A The Limits of Medicaid Reform in Pennsylvania 17 a smaller population than is possible with a state-governed structure. Fund- ing for CHBs is provided through a mix of federal, state, and local funding as well as fees and reimbursements. Non- categorical state funding provides the base funding for the CHBs in addition to targeted funding to address state- level public and community health priorities (Mays and Frauendienst 2014). A recent report measuring performance indicators on CHBs suggests that many work with local partners to increase health education programming, particu- larly in school settings. Also, most engage in activities to promote healthy behaviors, particularly nutrition and physical activity (Minnesota Depart- ment of Health 2014). Other program areas include maternal and child health, infectious disease prevention, and promotion of environmental health, such as radon testing. One of the challenges faced by Minnesota CHBs is funding. Even though the state provides significant governmental transfers, many CHBs struggle to provide sufficient local tax and non- tax revenue (Minnesota Department of Health 2015). Changes in population demographics, including the decline of rural populations, are another concern. In spite of these challenges, evidence suggests that there is increasing ability for CHBs to meet state performance standards and the state is encouraging all CHBs to apply for Public Health Department Accreditation, which would provide additional technical support and research to improve service delivery. Minnesota’s CHBs provide decen- tralized health centers with strong support from the state, providing residents more targeted services and programming to meet the unique needs of each region. Regional Public Health in Massachusetts If states such as Minnesota provide empirical support that legislative and administrative decentralization may help improve community health, Mas- sachusetts provides an example of the benefits of engaging public and private services providers in regionalizing public health. Massachusetts is both one of the healthiest states in the nation and characterized by one of the most decen- tralized systems of health. Historically, each municipality was responsible for providing public health services and acted as the primary funder for these services. In fact, until 2006, state law did not provide for the opportunity for any direct funding for public health. With over 300 communities and varying degrees of financial capacity, state leaders recognized that the existing system was no longer sustainable and that a more centralized approach, with greater state-level engagement, was needed to ensure equitable access to care for all citizens. 18 Michele Moser Deegan anD a. lanethea Mathews- schultz Following on the heels of the landmark Massachusetts health reform that was the precursor to the ACA, local health department and state officials prepared a report recommending several improvements to the public health system (Hyde and Tovar 2006). These recommendations, along with further study of the problems by public health leaders, led to the creation of several additional policy changes. First, in December 2006 the state launched the Massachusetts Public Health Regionalization Project with the goal of estab- lishing consortiums of local health departments across multi- jurisdictional boundaries to provide a “consistent standard of care and equal level of ser- vices.” (Massachusetts Public Health Regionalization Project 2016). Six regional consortiums received Public Health District Incentive Grants from the state, supported by a grant from the U.S. Center for Disease Control. These consortiums bring together local health boards and community health care provides to create regional health improvement plans and coordinate services. For example, the Central Massachusetts Regional Health Alliance, compris- ing seven local health boards and over 90 community organizations and hos- pitals, developed a strategic plan that includes a focus on health equity and health disparities (Central Massachusetts Regional Public Health Alliance 2014). Second, to further enable and encourage regionalization, in 2008 state policy makers revised Chapter 529, an Act Relative to Public Health Reorgani- zation, which removed barriers to regionalization. This law provides the legal basis for state funding for public health but retains legislative prerogative for development of the funding formula and subsequent annual funding. Third, in 2013, Massachusetts created the Office of Local and Regional Health, the hub for partnerships between the state Department of Health and Human Services and regional consortiums. This office is similar in scope to Pennsylvania’s Bureau of Community Health Systems. The evolution of the expansion of state efforts to support the new regional collaborative and local health boards is still relatively new. However, research by the Institute of Community Health points to early posi- tive outcomes in the District Incentive Grant Program and regional health consortium (Hays et al. 2014). Opportunities for Regionalizing Public Health in Pennsylvania Our goal here is not to suggest a one size fits all approach. To be sure, Mas- sachusetts and Minnesota are significantly different both from each other and from Pennsylvania culturally, politically, geographically, and economi- cally. Rather, our goal is to draw attention to the experiences in Minnesota The Limits of Medicaid Reform in Pennsylvania 19 and Massachusetts, and to emergent research on public health governance, to suggest that thinking regionally offers innovative routes for improving health care and population health outcomes. Pennsylvania is well positioned to encourage greater decentralization of public health by revising existing leg- islation to encourage a regionally driven public health system. For example, policymakers could consider revising Act 315 to provide greater incentives for counties and municipalities to create local health departments and multijuris- dictional health departments that include two or more counties as a regional economic entity. Regional health departments are beneficial for several reasons. First, by design, they would be attuned and responsive to residents within identified geographies, including at- risk populations in cities and suburbs. Currently operating Health Bureaus offer more expanded clinical services, environmen- tal health, and targeted community education opportunities to residents than do state-run health centers and are more adaptable to local community issues. Regional health departments, we expect, would provide the same attention to community needs. Second, regional health departments would increase community engagement in public health. Act 315 requires that county com- missioners appoint five residents within a health department’s geographic boundary to serve on a Board of Health, ensuring greater localized autonomy over public health provisions than is current practice in most counties in the state. The third benefit is that localized health departments would provide opportunities for greater coordination of regional health services including, for example, county departments of Human Services in the areas of mental health, aging, and children and youth services. Regional health departments would also have greater ability to coordinate services directly with nonprofit and private providers to improve regional health as shown through the exam- ples of CHBs and Regional Health Departments in Massachusetts. If regionalizing Pennsylvania’s approach to health is a good idea, and we think it is, there are important funding, cost, and political considerations (we say more on this below). A large question, in light of current state budget woes, is funding. Deeper consideration of the cost of implementation is necessary; however one assumption is that expenditures for state health centers would be shifted from the current state health centers, which would no longer be needed, to the new regional entities. Further funding would be raised through local sources, federal grants, and service provision. An even more politically feasible and practical step toward thinking regionally is to encourage growth and proliferation of FQHC/RHCs and sim- ilar organizations providing community-level primary care. FQHC/RHCs receive funding from the Health Resources and Services Administration of 20 Michele Moser Deegan anD a. lanethea Mathews- schultz the U.S. Department of Health and Human Services. Maximizing the poten- tial for federal funding by providing additional state funds to organizations operating within high- need locations would serve those most in need of affordable health services. Combined, these efforts would provide a better foundation for reducing health disparities by recognizing the importance of regional health planning that includes collaboration with neighboring government entities as well as nonprofit and private-sector providers. Regional Case Study of the Lehigh Valley Figure 4 provides an example for thinking regionally in the way that we imag- ine by examining the spatial relationships of public health offices and FQHCs in the Lehigh Valley region of Pennsylvania. The Lehigh Valley region com- prises Lehigh and Northampton Counties, 62 municipalities, and 17 school districts. The Valley is home to approximately 600,000 residents, with median income ranging from $54,923 to $60,097. Approximately 14% of Lehigh Figure 4. Percentage Uninsured up to 138 FPL by Census Tract, Lehigh and Northampton Counties. (U.S. Census Bureau, American Community Survey, 2008–2013; Pennsylvania Department of Health; and Pennsylvania Association of Community Health Centers.). The Limits of Medicaid Reform in Pennsylvania 21 County lives at 100 FPL; in Northampton, the poverty rate is just under 10%. Lehigh County is home to Allentown, the third largest city in the Common- wealth, with a poverty rate of 28%. As shown in Figure 4, the state operates a health center in each county, while the cities of Allentown and Bethlehem have their own Health Bureaus. There is also an FQHC located in Allentown. Given Allentown’s relatively high poverty rate, it is an obvious place to locate services designed to provide affordable health care. Nonetheless, closer examination of census tracts in the Lehigh Valley as a whole suggests there are other places in the region that would benefit from more accessible health care. Following Governor Wolf ’s expansion of traditional Medicaid, we would expect most areas on Figure 4 to show fewer uninsured over time, as more individuals register for HealthChoices in the coming years. Indeed, recall our discussion above and Appendix A, which shows that Lehigh and Northamp- ton exceed the statewide average rate of change in Medicaid enrollments in the year stretching from June 2014 to June 2015. Lehigh’s Medicaid enroll- ment increased by about 22%; in Northampton, the increase was almost 24%. We expect that some of these individuals will now seek more frequent primary and preventative care. However, like many regions in the state, the Lehigh Valley is characterized by barriers to health care and improved health outcomes that cannot be overcome simply through the extension of health insurance. Community health needs assessments in the region conducted in compliance with the requirements of the Affordable Care Act have demon- strated, for example, that transportation, housing, employment, and cultural and language barriers are important factors explaining disparities in health outcomes and access to preventive health services (Mathews 2012; Mathews- Schultz and Brill 2015). Further, the needs of residents living in the urban core areas of the Lehigh Valley differ from those living in the suburban and rural outskirts of the region; access (particularly for residents lacking trans- portation) is particularly significant in the rural areas. Communities in the northern and southern tiers of the Lehigh Valley, for example, lack access to the region’s bus system, the only form of public transportation. Interestingly, policy and county leaders in the Lehigh Valley previously took steps toward creating a bicounty health department in the region. Les- sons from this experience reveal both the appeal of thinking regionally about health and the practical and political barriers to implementing regionalism without clear incentives and support from state (and possible) federal insti- tutions. In 2010, several organizations within the health care community in Lehigh and Northampton Counties, including the two municipal health bureaus, Two Rivers Health Foundation, and the local hospitals, proposed the creation of a new bureau that would replace the existing Allentown and 22 Michele Moser Deegan anD a. lanethea Mathews- schultz Bethlehem Health Bureaus. That proposal was for a larger multicounty entity that would offer expanded services and new locations in Easton, Bangor, and Slatington, three areas with a large number of low-i ncome residents that tend to be underserved by the existing urban core health bureaus. Unfortunately, despite empirical evidence that a bicounty health depart- ment would better serve the health needs of the region’s low- income pop- ulation, these efforts failed to gain enough political support among either Lehigh or Northampton County political elites and elected leaders who had to approve its creation. The main sticking point for the county commissioners and opponents of the regional health department stemmed from the proposed expectation that each county and the three cities would contribute resources to operate the new bureau. In the midst of the recession, and with Tea Party Republicans on both the Lehigh and Northampton county councils opposed to increasing the size of government, this requirement was not politically viable. It is likely that opposition to regional health bureaus will continue without state-level reforms to decentralize public health similar to those in Minnesota and Massachusetts and incentives to make it easier for regions to expand autonomy and accountability. Moving Forward after Obamacare: Tentative Conclusions and New Questions It is certain that large numbers of low- income previously uninsured Pennsyl- vanians will gain health insurance as a result of the state’s Medicaid expansion. Early indications suggest that, in the first half of 2015, a far greater number of residents enrolled in HealthChoices—the newly designed and named state- run Medicaid program—than enrolled in the private health marketplace cre- ated under Obamacare. It is difficult to overstate the significance of Medicaid in extending health insurance to low- income residents in the state. More than 400,000 Pennsylvania residents are newly insured as a result of the Medicaid expansion. With this backdrop, our primary goal in this article was to suggest that the pre- existing landscape of health inequalities in access to care across different regions of the state, coupled with the centralized hybrid structure of health governance, will mediate and potentially limit health outcomes among the newly insured population. Better and more health insurance will not nec- essarily lead to better health care or improved health outcomes. Access to preventive health services and primary care physicians is not distributed equi- tably across the state; those newly insured and those who remain uninsured The Limits of Medicaid Reform in Pennsylvania 23 will have differential access to health care depending to large degree on where they live. Emergent literature on regionalism and public health, coupled with expe- riences of innovative regional approaches in states such as Minnesota and Massachusetts, suggest that there are tangible ways Pennsylvania (and other states) can think regionally about how to best address inequalities in access to health. Many academics, research institutions (see, for example, the Insti- tute for Public Policy and Economic Development), and practitioners advocate statewide regionalization for many policy areas beyond health. For example, these areas include police, fire, public education, water and wastewater, eco- nomic development, transportation, and planning. Statewide obstacles similar to those found in the Lehigh Valley have frus- trated these efforts to regionalize while, ironically, the fragmentation of Penn- sylvania’s local governments further contributes to service delivery challenges and fiscal stress. Nonetheless, there has been limited success in regionaliza- tion that gives us reason for optimism. Since 1971, for instance, 29 regional Intermediate Units (IUs), multijurisdictional entities, have provided educa- tional services and instruction. IUs operate as a statewide network to pro- vide services to school districts and other educational entities that would not be provided if each district were expected to provide its own services; while IUs cannot raise their own tax revenues, they do charge fees for service and receive state and local funding (Joint State Government Commission 1997). There are other examples of successful regionalization in the state; there are at least 35 regional police departments across 125 municipalities, and inter- state and intrastate regional planning commissions are now commonplace throughout the Northeast. As we have shown throughout this article, Pennsylvania’s health system requires an overhaul. Pennsylvania continues to rank below national aver- ages on measures of state population health. The Kaiser Commission recently reported that individuals living in rural areas of the state are most likely to face the greatest obstacles in accessing health care and in obtaining improved health outcomes. A State Health Care Innovation Plan awarded to Pennsyl- vania in 2013 has begun the development of telemedicine initiatives to help address some of these disparities (Kaiser Commission on Medicaid and the Uninsured 2016). While a worthy goal, the above suggests that without a more regionalized strategic focus on services and service access barriers, many low- income Pennsylvanians will continue to lack access to health care and improved health, even if newly insured as a result of the ACA Medicaid expansion. 24 A XI D N P P E A ta bl e a .1 . P op ul at io n, u ni ns ur ed , an d M ed ic ai d e nr ol le es P re - an d P os t- M ed ic ai d e xp an si on   to ta l P op ul at io n (2 0 1 3 ) P op ul at io n 1 8 –6 4 u nd er 1 3 8 F P l (2 0 1 3 ) n um be r 1 8 –6 4 Y ea rs o ld u nd er 1 3 8 F P l u ni ns ur ed (2 0 1 3 ) P er ce nt ag e P op ul at io n 1 8 –6 4 un de r 1 3 8 F P l u ni ns ur ed Ju ne 2 0 1 4 a du lt M ed ic ai d e nr ol le es Ju ne 2 0 1 5 a du lt M ed ic ai d e nr ol le es P er ce nt ag e c ha ng e in a du lt M ed ic ai d e nr ol le es Ju ne 2 0 1 4 – Ju ne 2 0 1 5 s ta te t o ta l 1 2 ,3 1 1 ,6 4 4 1 ,3 8 0 ,0 8 2 3 9 9 ,0 8 6 2 8 .9 2 % 1 ,1 2 6 ,3 9 6 1 ,3 8 3 ,6 7 5 1 8 .6 % A da m s 9 6 ,9 2 5 7 ,4 9 6 2 ,9 2 0 3 8 .9 5 % 5 ,0 0 1 6 ,7 2 1 2 5 .6 % A lle gh en y 1 ,1 9 3 ,2 8 5 1 3 2 ,0 8 5 3 3 ,7 8 3 2 5 .5 8 % 1 0 2 ,1 7 6 1 2 2 ,4 9 6 1 6 .6 % A rm st ro ng 6 7 ,7 9 4 7 ,6 2 7 2 ,2 4 0 2 9 .3 7 % 7 ,2 4 2 8 ,5 7 9 1 5 .6 % B ea ve r 1 6 7 ,2 3 4 1 6 ,2 5 7 3 ,7 4 1 2 3 .0 1 % 1 5 ,7 3 4 1 8 ,8 9 8 1 6 .7 % B ed fo rd 4 8 ,6 4 6 5 ,3 5 5 1 ,6 5 6 3 0 .9 2 % 4 ,8 2 3 6 ,0 7 4 2 0 .6 % B er ks 3 9 8 ,8 9 4 4 3 ,6 7 4 1 4 ,4 8 2 3 3 .1 6 % 3 4 ,5 9 4 4 2 ,2 2 2 1 8 .1 % B la ir 1 2 3 ,6 0 7 1 5 ,2 7 4 3 ,6 5 9 2 3 .9 6 % 1 4 ,3 4 3 1 7 ,3 1 3 1 7 .2 % B ra df or d 6 1 ,5 5 5 7 ,2 6 8 2 ,2 4 6 3 0 .9 0 % 5 ,7 4 5 6 ,7 6 9 1 5 .1 % B uc ks 6 1 7 ,1 6 1 3 0 ,3 6 6 9 ,2 3 4 3 0 .4 1 % 2 8 ,2 0 6 3 5 ,9 9 2 2 1 .6 % B ut le r 1 7 9 ,4 0 1 1 5 ,3 1 1 4 ,3 1 0 2 8 .1 5 % 1 0 ,8 6 2 1 3 ,3 2 4 1 8 .5 % C am br ia 1 3 4 ,4 9 5 1 6 ,0 1 8 4 ,5 7 9 2 8 .5 9 % 1 5 ,1 2 5 1 8 ,0 9 5 1 6 .4 % C am er on 4 ,9 2 3 4 9 4 1 1 8 2 3 .8 9 % 6 4 0 7 3 8 1 3 .3 % C ar bo n 6 4 ,0 7 4 6 ,8 7 6 1 ,9 7 6 2 8 .7 4 % 4 ,9 6 0 6 ,3 1 2 2 1 .4 % C en tr e 1 3 7 ,1 1 0 2 8 ,2 5 4 3 ,9 0 4 1 3 .8 2 % 6 ,3 4 7 7 ,9 8 7 2 0 .5 % C he st er 4 9 0 ,1 9 9 2 9 ,6 6 2 1 0 ,1 5 0 3 4 .2 2 % 1 6 ,9 4 5 2 2 ,4 1 5 2 4 .4 % C la ri on 3 7 ,8 5 5 5 ,9 5 3 1 ,3 4 1 2 2 .5 3 % 3 ,8 6 7 4 ,5 2 0 1 4 .4 % C le ar fi el d 7 6 ,4 6 3 9 ,9 5 3 3 ,0 5 0 3 0 .6 4 % 9 ,6 6 6 1 1 ,4 4 8 1 5 .6 % C lin to n 3 6 ,7 6 9 5 ,2 1 8 9 8 9 1 8 .9 5 % 3 ,9 5 3 4 ,6 1 0 1 4 .3 % C ol um bi a 6 2 ,7 6 3 9 ,6 8 5 2 ,0 9 0 2 1 .5 8 % 5 ,4 1 3 6 ,5 6 5 1 7 .5 % C ra w fo rd 8 4 ,3 2 7 1 1 ,5 2 6 3 ,5 6 5 3 0 .9 3 % 9 ,1 1 7 1 0 ,6 8 4 1 4 .7 % C um be rl an d 2 2 3 ,2 6 2 1 6 ,9 4 1 4 ,7 5 1 2 8 .0 4 % 1 0 ,9 8 4 1 4 ,3 4 9 2 3 .5 % D au ph in 2 6 2 ,8 7 8 2 8 ,3 7 0 8 ,5 6 0 3 0 .1 7 % 2 2 ,0 9 3 2 9 ,6 4 8 2 5 .5 % D el aw ar e 5 3 8 ,1 2 8 4 5 ,1 8 0 1 3 ,4 2 1 2 9 .7 1 % 4 2 ,2 1 6 4 9 ,1 2 7 1 4 .1 % E lk 3 1 ,4 1 1 2 ,5 2 8 5 1 7 2 0 .4 5 % 2 ,7 2 8 3 ,1 3 3 1 2 .9 % E ri e 2 6 8 ,0 4 4 3 7 ,0 0 3 9 ,1 6 1 2 4 .7 6 % 3 1 ,3 8 7 3 8 ,4 6 9 1 8 .4 % Fa ye tt e 1 3 2 ,1 3 8 2 0 ,2 8 6 6 ,1 0 1 3 0 .0 7 % 2 0 ,1 9 9 2 3 ,7 8 5 1 5 .1 % Fo re st 4 ,8 0 3 6 9 0 2 2 5 3 2 .6 1 % 5 7 4 7 1 5 1 9 .7 % Fr an kl in 1 4 7 ,6 4 0 1 3 ,3 5 4 5 ,3 2 0 3 9 .8 4 % 9 ,3 3 3 1 2 ,3 9 6 2 4 .7 % Fu lt on 1 4 ,6 4 1 1 ,5 1 9 4 5 8 3 0 .1 5 % 1 ,3 4 7 1 ,6 3 4 1 7 .6 % G re en e 3 4 ,0 8 9 4 ,4 7 2 1 ,1 9 5 2 6 .7 2 % 4 ,4 2 9 5 ,1 2 2 1 3 .5 % H un ti ng do n 4 0 ,6 8 8 4 ,5 7 9 1 ,1 9 6 2 6 .1 2 % 4 ,3 2 2 5 ,1 3 1 1 5 .8 % In di an a 8 3 ,2 1 9 1 3 ,9 0 3 3 ,4 9 6 2 5 .1 5 % 7 ,4 1 5 9 ,4 3 3 2 1 .4 % Je ff er so n 4 4 ,1 7 4 5 ,5 3 5 1 ,5 8 5 2 8 .6 4 % 5 ,1 2 8 5 ,9 8 4 1 4 .3 % Ju ni at a 2 4 ,3 5 9 2 ,6 5 9 9 1 0 3 4 .2 2 % 1 ,8 2 8 2 ,1 6 5 1 5 .6 % 25 A P P E N D IX A ta bl e a .1 . P op ul at io n, u ni ns ur ed , an d M ed ic ai d e nr ol le es P re - an d P os t- M ed ic ai d e xp an si on   to ta l P op ul at io n (2 0 1 3 ) P op ul at io n 1 8 –6 4 u nd er 1 3 8 F P l (2 0 1 3 ) n um be r 1 8 –6 4 Y ea rs o ld u nd er 1 3 8 F P l u ni ns ur ed (2 0 1 3 ) P er ce nt ag e P op ul at io n 1 8 –6 4 un de r 1 3 8 F P l u ni ns ur ed Ju ne 2 0 1 4 a du lt M ed ic ai d e nr ol le es Ju ne 2 0 1 5 a du lt M ed ic ai d e nr ol le es P er ce nt ag e c ha ng e in a du lt M ed ic ai d e nr ol le es Ju ne 2 0 1 4 – Ju ne 2 0 1 5 s ta te t o ta l 1 2 ,3 1 1 ,6 4 4 1 ,3 8 0 ,0 8 2 3 9 9 ,0 8 6 2 8 .9 2 % 1 ,1 2 6 ,3 9 6 1 ,3 8 3 ,6 7 5 1 8 .6 % A da m s 9 6 ,9 2 5 7 ,4 9 6 2 ,9 2 0 3 8 .9 5 % 5 ,0 0 1 6 ,7 2 1 2 5 .6 % A lle gh en y 1 ,1 9 3 ,2 8 5 1 3 2 ,0 8 5 3 3 ,7 8 3 2 5 .5 8 % 1 0 2 ,1 7 6 1 2 2 ,4 9 6 1 6 .6 % A rm st ro ng 6 7 ,7 9 4 7 ,6 2 7 2 ,2 4 0 2 9 .3 7 % 7 ,2 4 2 8 ,5 7 9 1 5 .6 % B ea ve r 1 6 7 ,2 3 4 1 6 ,2 5 7 3 ,7 4 1 2 3 .0 1 % 1 5 ,7 3 4 1 8 ,8 9 8 1 6 .7 % B ed fo rd 4 8 ,6 4 6 5 ,3 5 5 1 ,6 5 6 3 0 .9 2 % 4 ,8 2 3 6 ,0 7 4 2 0 .6 % B er ks 3 9 8 ,8 9 4 4 3 ,6 7 4 1 4 ,4 8 2 3 3 .1 6 % 3 4 ,5 9 4 4 2 ,2 2 2 1 8 .1 % B la ir 1 2 3 ,6 0 7 1 5 ,2 7 4 3 ,6 5 9 2 3 .9 6 % 1 4 ,3 4 3 1 7 ,3 1 3 1 7 .2 % B ra df or d 6 1 ,5 5 5 7 ,2 6 8 2 ,2 4 6 3 0 .9 0 % 5 ,7 4 5 6 ,7 6 9 1 5 .1 % B uc ks 6 1 7 ,1 6 1 3 0 ,3 6 6 9 ,2 3 4 3 0 .4 1 % 2 8 ,2 0 6 3 5 ,9 9 2 2 1 .6 % B ut le r 1 7 9 ,4 0 1 1 5 ,3 1 1 4 ,3 1 0 2 8 .1 5 % 1 0 ,8 6 2 1 3 ,3 2 4 1 8 .5 % C am br ia 1 3 4 ,4 9 5 1 6 ,0 1 8 4 ,5 7 9 2 8 .5 9 % 1 5 ,1 2 5 1 8 ,0 9 5 1 6 .4 % C am er on 4 ,9 2 3 4 9 4 1 1 8 2 3 .8 9 % 6 4 0 7 3 8 1 3 .3 % C ar bo n 6 4 ,0 7 4 6 ,8 7 6 1 ,9 7 6 2 8 .7 4 % 4 ,9 6 0 6 ,3 1 2 2 1 .4 % C en tr e 1 3 7 ,1 1 0 2 8 ,2 5 4 3 ,9 0 4 1 3 .8 2 % 6 ,3 4 7 7 ,9 8 7 2 0 .5 % C he st er 4 9 0 ,1 9 9 2 9 ,6 6 2 1 0 ,1 5 0 3 4 .2 2 % 1 6 ,9 4 5 2 2 ,4 1 5 2 4 .4 % C la ri on 3 7 ,8 5 5 5 ,9 5 3 1 ,3 4 1 2 2 .5 3 % 3 ,8 6 7 4 ,5 2 0 1 4 .4 % C le ar fi el d 7 6 ,4 6 3 9 ,9 5 3 3 ,0 5 0 3 0 .6 4 % 9 ,6 6 6 1 1 ,4 4 8 1 5 .6 % C lin to n 3 6 ,7 6 9 5 ,2 1 8 9 8 9 1 8 .9 5 % 3 ,9 5 3 4 ,6 1 0 1 4 .3 % C ol um bi a 6 2 ,7 6 3 9 ,6 8 5 2 ,0 9 0 2 1 .5 8 % 5 ,4 1 3 6 ,5 6 5 1 7 .5 % C ra w fo rd 8 4 ,3 2 7 1 1 ,5 2 6 3 ,5 6 5 3 0 .9 3 % 9 ,1 1 7 1 0 ,6 8 4 1 4 .7 % C um be rl an d 2 2 3 ,2 6 2 1 6 ,9 4 1 4 ,7 5 1 2 8 .0 4 % 1 0 ,9 8 4 1 4 ,3 4 9 2 3 .5 % D au ph in 2 6 2 ,8 7 8 2 8 ,3 7 0 8 ,5 6 0 3 0 .1 7 % 2 2 ,0 9 3 2 9 ,6 4 8 2 5 .5 % D el aw ar e 5 3 8 ,1 2 8 4 5 ,1 8 0 1 3 ,4 2 1 2 9 .7 1 % 4 2 ,2 1 6 4 9 ,1 2 7 1 4 .1 % E lk 3 1 ,4 1 1 2 ,5 2 8 5 1 7 2 0 .4 5 % 2 ,7 2 8 3 ,1 3 3 1 2 .9 % E ri e 2 6 8 ,0 4 4 3 7 ,0 0 3 9 ,1 6 1 2 4 .7 6 % 3 1 ,3 8 7 3 8 ,4 6 9 1 8 .4 % Fa ye tt e 1 3 2 ,1 3 8 2 0 ,2 8 6 6 ,1 0 1 3 0 .0 7 % 2 0 ,1 9 9 2 3 ,7 8 5 1 5 .1 % Fo re st 4 ,8 0 3 6 9 0 2 2 5 3 2 .6 1 % 5 7 4 7 1 5 1 9 .7 % Fr an kl in 1 4 7 ,6 4 0 1 3 ,3 5 4 5 ,3 2 0 3 9 .8 4 % 9 ,3 3 3 1 2 ,3 9 6 2 4 .7 % Fu lt on 1 4 ,6 4 1 1 ,5 1 9 4 5 8 3 0 .1 5 % 1 ,3 4 7 1 ,6 3 4 1 7 .6 % G re en e 3 4 ,0 8 9 4 ,4 7 2 1 ,1 9 5 2 6 .7 2 % 4 ,4 2 9 5 ,1 2 2 1 3 .5 % H un ti ng do n 4 0 ,6 8 8 4 ,5 7 9 1 ,1 9 6 2 6 .1 2 % 4 ,3 2 2 5 ,1 3 1 1 5 .8 % In di an a 8 3 ,2 1 9 1 3 ,9 0 3 3 ,4 9 6 2 5 .1 5 % 7 ,4 1 5 9 ,4 3 3 2 1 .4 % Je ff er so n 4 4 ,1 7 4 5 ,5 3 5 1 ,5 8 5 2 8 .6 4 % 5 ,1 2 8 5 ,9 8 4 1 4 .3 % Ju ni at a 2 4 ,3 5 9 2 ,6 5 9 9 1 0 3 4 .2 2 % 1 ,8 2 8 2 ,1 6 5 1 5 .6 % 26 ta bl e a .1 ( co nt in ue d)   to ta l P op ul at io n (2 0 1 3 ) P op ul at io n 1 8 –6 4 u nd er 1 3 8 F P l (2 0 1 3 ) n um be r 1 8 –6 4 Y ea rs o ld u nd er 1 3 8 F P l u ni ns ur ed (2 0 1 3 ) P er ce nt ag e P op ul at io n 1 8 –6 4 un de r 1 3 8 F P l u ni ns ur ed Ju ne 2 0 1 4 a du lt M ed ic ai d e nr ol le es Ju ne 2 0 1 5 a du lt M ed ic ai d e nr ol le es P er ce nt ag e c ha ng e in a du lt M ed ic ai d e nr ol le es Ju ne 2 0 1 4 – Ju ne 2 0 1 5 La ck aw an na 2 0 6 ,3 1 8 2 3 ,2 3 0 6 ,4 5 9 2 7 .8 0 % 2 1 ,4 5 0 2 6 ,5 3 2 1 9 .2 % La nc as te r 5 0 8 ,3 9 7 4 5 ,9 3 5 1 4 ,7 5 6 3 2 .1 2 % 3 4 ,4 5 9 4 2 ,8 4 7 1 9 .6 % La w re nc e 8 7 ,9 0 4 1 0 ,0 4 0 2 ,9 7 3 2 9 .6 1 % 9 ,6 4 7 1 1 ,7 0 3 1 7 .6 % Le ba no n 1 3 0 ,6 2 0 1 1 ,1 3 7 3 ,4 6 1 3 1 .0 8 % 9 ,5 2 9 1 2 ,3 9 4 2 3 .1 % Le hi gh 3 4 2 ,3 0 1 3 7 ,3 4 2 1 3 ,1 6 3 3 5 .2 5 % 3 0 ,7 9 2 3 9 ,3 3 7 2 1 .7 % Lu ze rn e 3 0 9 ,2 0 0 3 7 ,7 1 9 1 1 ,6 4 6 3 0 .8 8 % 3 2 ,5 3 1 4 0 ,1 9 7 1 9 .1 % Ly co m in g 1 1 1 ,1 2 9 1 3 ,6 1 9 3 ,7 8 2 2 7 .7 7 % 1 1 ,1 2 1 1 3 ,5 8 6 1 8 .1 % M cK ea n 4 0 ,0 3 9 5 ,6 2 0 1 ,4 1 4 2 5 .1 6 % 4 ,9 4 7 5 ,9 6 8 1 7 .1 % M er ce r 1 0 8 ,8 5 4 1 2 ,6 6 1 3 ,3 7 6 2 6 .6 6 % 1 2 ,7 5 4 1 4 ,7 4 5 1 3 .5 % M if fl in 4 6 ,0 6 9 6 ,1 8 2 2 ,1 3 5 3 4 .5 4 % 5 ,2 5 8 6 ,0 7 6 1 3 .5 % M on ro e 1 ,6 5 2 ,2 0 2 1 8 ,3 4 6 6 ,0 5 8 3 3 .0 2 % 1 3 ,3 6 7 1 6 ,9 1 6 2 1 .0 % M on tg om er y 7 8 4 ,2 0 2 4 2 ,4 6 4 1 2 ,9 6 8 3 0 .5 4 % 3 7 ,1 1 2 4 9 ,4 7 1 2 5 .0 % M on to ur 1 7 ,7 5 7 1 ,5 9 1 5 3 5 3 3 .6 3 % 1 ,5 3 0 1 ,7 3 1 1 1 .6 % N or th am pt on 2 8 7 ,1 1 3 2 3 ,6 9 3 6 ,5 7 4 2 7 .7 5 % 1 9 ,8 0 3 2 6 ,0 3 4 2 3 .9 % N or th um be rl an d 8 9 ,8 5 2 1 1 ,1 6 3 3 ,9 1 1 3 5 .0 4 % 9 ,5 5 2 1 1 ,6 8 4 1 8 .2 % P er ry 4 5 ,0 6 1 3 ,5 7 8 1 ,2 4 3 3 4 .7 4 % 2 ,7 3 9 3 ,4 3 1 2 0 .2 % P hi la de lp hi a 1 ,4 9 3 ,7 4 5 3 1 6 ,9 5 2 8 8 ,6 9 6 2 7 .9 8 % 2 7 1 ,4 8 6 3 2 6 ,4 7 3 1 6 .8 % P ik e 5 6 ,4 1 4 5 ,0 0 0 1 ,8 5 1 3 7 .0 2 % 3 ,3 9 9 4 ,7 5 0 2 8 .4 % P ot te r 1 7 ,1 7 0 2 ,1 5 8 6 8 3 3 1 .6 5 % 1 ,7 9 1 2 ,1 5 1 1 6 .7 % S ch uy lk ill 1 4 0 ,1 7 7 1 5 ,8 5 2 5 ,0 2 3 3 1 .6 9 % 1 4 ,5 8 6 1 7 ,6 3 2 1 7 .3 % S ny de r 3 7 ,3 1 4 3 ,7 4 9 1 ,3 6 3 3 6 .3 6 % 2 ,8 5 5 3 ,4 8 2 1 8 .0 % S om er se t 7 3 ,0 4 2 7 ,6 5 5 2 ,4 2 9 3 1 .7 3 % 6 ,7 3 6 8 ,4 3 7 2 0 .2 % S ul liv an 6 ,2 5 1 8 1 9 2 1 8 2 6 .6 2 % 6 1 4 7 3 3 1 6 .2 % S us qu eh an na 4 2 ,3 6 6 5 ,2 3 2 1 ,7 7 9 3 4 .0 0 % 3 ,0 6 7 3 ,7 9 5 1 9 .2 % Ti og a 4 0 ,4 9 2 5 ,2 8 2 1 ,7 5 4 3 3 .2 1 % 3 ,5 6 8 4 ,6 3 8 2 3 .1 % U ni on 3 5 ,7 2 9 4 ,1 1 5 1 ,1 2 7 2 7 .3 9 % 2 ,4 2 0 2 ,8 3 7 1 4 .7 % Ve na ng o 5 3 ,3 4 2 6 ,7 5 0 1 ,8 2 2 2 6 .9 9 % 6 ,0 9 6 7 ,1 2 7 1 4 .5 % W ar re n 4 0 ,4 4 0 4 ,4 5 0 1 ,4 0 4 3 1 .5 5 % 3 ,7 8 2 4 ,4 9 6 1 5 .9 % W as hi ng to n 2 0 3 ,1 7 9 1 9 ,6 3 4 5 ,3 9 0 2 7 .4 5 % 1 6 ,0 5 8 1 9 ,6 7 2 1 8 .4 % W ay ne 4 8 ,5 5 4 5 ,1 6 2 1 ,4 8 1 2 8 .6 9 % 4 ,3 0 9 5 ,3 4 7 1 9 .4 % W es tm or el an d 3 5 5 ,9 2 4 3 2 ,7 7 8 8 ,2 8 4 2 5 .2 7 % 3 0 ,0 5 4 3 6 ,5 3 3 1 7 .7 % W yo m in g 2 7 ,3 9 4 2 ,8 9 2 7 2 7 2 5 .1 4 % 2 ,1 4 2 2 ,7 4 0 2 1 .8 % Yo rk 4 2 7 ,1 4 0 3 6 ,3 1 1 1 2 ,6 7 2 3 4 .9 0 % 2 8 ,1 0 0 3 7 ,3 2 7 2 4 .7 % So ur ce : U .S . C en su s B ur ea u, A m er ic an C om m un it y S ur ve y, 2 01 1– 2 01 6 . 27 ta bl e a .1 ( co nt in ue d)   to ta l P op ul at io n (2 0 1 3 ) P op ul at io n 1 8 –6 4 u nd er 1 3 8 F P l (2 0 1 3 ) n um be r 1 8 –6 4 Y ea rs o ld u nd er 1 3 8 F P l u ni ns ur ed (2 0 1 3 ) P er ce nt ag e P op ul at io n 1 8 –6 4 un de r 1 3 8 F P l u ni ns ur ed Ju ne 2 0 1 4 a du lt M ed ic ai d e nr ol le es Ju ne 2 0 1 5 a du lt M ed ic ai d e nr ol le es P er ce nt ag e c ha ng e in a du lt M ed ic ai d e nr ol le es Ju ne 2 0 1 4 – Ju ne 2 0 1 5 La ck aw an na 2 0 6 ,3 1 8 2 3 ,2 3 0 6 ,4 5 9 2 7 .8 0 % 2 1 ,4 5 0 2 6 ,5 3 2 1 9 .2 % La nc as te r 5 0 8 ,3 9 7 4 5 ,9 3 5 1 4 ,7 5 6 3 2 .1 2 % 3 4 ,4 5 9 4 2 ,8 4 7 1 9 .6 % La w re nc e 8 7 ,9 0 4 1 0 ,0 4 0 2 ,9 7 3 2 9 .6 1 % 9 ,6 4 7 1 1 ,7 0 3 1 7 .6 % Le ba no n 1 3 0 ,6 2 0 1 1 ,1 3 7 3 ,4 6 1 3 1 .0 8 % 9 ,5 2 9 1 2 ,3 9 4 2 3 .1 % Le hi gh 3 4 2 ,3 0 1 3 7 ,3 4 2 1 3 ,1 6 3 3 5 .2 5 % 3 0 ,7 9 2 3 9 ,3 3 7 2 1 .7 % Lu ze rn e 3 0 9 ,2 0 0 3 7 ,7 1 9 1 1 ,6 4 6 3 0 .8 8 % 3 2 ,5 3 1 4 0 ,1 9 7 1 9 .1 % Ly co m in g 1 1 1 ,1 2 9 1 3 ,6 1 9 3 ,7 8 2 2 7 .7 7 % 1 1 ,1 2 1 1 3 ,5 8 6 1 8 .1 % M cK ea n 4 0 ,0 3 9 5 ,6 2 0 1 ,4 1 4 2 5 .1 6 % 4 ,9 4 7 5 ,9 6 8 1 7 .1 % M er ce r 1 0 8 ,8 5 4 1 2 ,6 6 1 3 ,3 7 6 2 6 .6 6 % 1 2 ,7 5 4 1 4 ,7 4 5 1 3 .5 % M if fl in 4 6 ,0 6 9 6 ,1 8 2 2 ,1 3 5 3 4 .5 4 % 5 ,2 5 8 6 ,0 7 6 1 3 .5 % M on ro e 1 ,6 5 2 ,2 0 2 1 8 ,3 4 6 6 ,0 5 8 3 3 .0 2 % 1 3 ,3 6 7 1 6 ,9 1 6 2 1 .0 % M on tg om er y 7 8 4 ,2 0 2 4 2 ,4 6 4 1 2 ,9 6 8 3 0 .5 4 % 3 7 ,1 1 2 4 9 ,4 7 1 2 5 .0 % M on to ur 1 7 ,7 5 7 1 ,5 9 1 5 3 5 3 3 .6 3 % 1 ,5 3 0 1 ,7 3 1 1 1 .6 % N or th am pt on 2 8 7 ,1 1 3 2 3 ,6 9 3 6 ,5 7 4 2 7 .7 5 % 1 9 ,8 0 3 2 6 ,0 3 4 2 3 .9 % N or th um be rl an d 8 9 ,8 5 2 1 1 ,1 6 3 3 ,9 1 1 3 5 .0 4 % 9 ,5 5 2 1 1 ,6 8 4 1 8 .2 % P er ry 4 5 ,0 6 1 3 ,5 7 8 1 ,2 4 3 3 4 .7 4 % 2 ,7 3 9 3 ,4 3 1 2 0 .2 % P hi la de lp hi a 1 ,4 9 3 ,7 4 5 3 1 6 ,9 5 2 8 8 ,6 9 6 2 7 .9 8 % 2 7 1 ,4 8 6 3 2 6 ,4 7 3 1 6 .8 % P ik e 5 6 ,4 1 4 5 ,0 0 0 1 ,8 5 1 3 7 .0 2 % 3 ,3 9 9 4 ,7 5 0 2 8 .4 % P ot te r 1 7 ,1 7 0 2 ,1 5 8 6 8 3 3 1 .6 5 % 1 ,7 9 1 2 ,1 5 1 1 6 .7 % S ch uy lk ill 1 4 0 ,1 7 7 1 5 ,8 5 2 5 ,0 2 3 3 1 .6 9 % 1 4 ,5 8 6 1 7 ,6 3 2 1 7 .3 % S ny de r 3 7 ,3 1 4 3 ,7 4 9 1 ,3 6 3 3 6 .3 6 % 2 ,8 5 5 3 ,4 8 2 1 8 .0 % S om er se t 7 3 ,0 4 2 7 ,6 5 5 2 ,4 2 9 3 1 .7 3 % 6 ,7 3 6 8 ,4 3 7 2 0 .2 % S ul liv an 6 ,2 5 1 8 1 9 2 1 8 2 6 .6 2 % 6 1 4 7 3 3 1 6 .2 % S us qu eh an na 4 2 ,3 6 6 5 ,2 3 2 1 ,7 7 9 3 4 .0 0 % 3 ,0 6 7 3 ,7 9 5 1 9 .2 % Ti og a 4 0 ,4 9 2 5 ,2 8 2 1 ,7 5 4 3 3 .2 1 % 3 ,5 6 8 4 ,6 3 8 2 3 .1 % U ni on 3 5 ,7 2 9 4 ,1 1 5 1 ,1 2 7 2 7 .3 9 % 2 ,4 2 0 2 ,8 3 7 1 4 .7 % Ve na ng o 5 3 ,3 4 2 6 ,7 5 0 1 ,8 2 2 2 6 .9 9 % 6 ,0 9 6 7 ,1 2 7 1 4 .5 % W ar re n 4 0 ,4 4 0 4 ,4 5 0 1 ,4 0 4 3 1 .5 5 % 3 ,7 8 2 4 ,4 9 6 1 5 .9 % W as hi ng to n 2 0 3 ,1 7 9 1 9 ,6 3 4 5 ,3 9 0 2 7 .4 5 % 1 6 ,0 5 8 1 9 ,6 7 2 1 8 .4 % W ay ne 4 8 ,5 5 4 5 ,1 6 2 1 ,4 8 1 2 8 .6 9 % 4 ,3 0 9 5 ,3 4 7 1 9 .4 % W es tm or el an d 3 5 5 ,9 2 4 3 2 ,7 7 8 8 ,2 8 4 2 5 .2 7 % 3 0 ,0 5 4 3 6 ,5 3 3 1 7 .7 % W yo m in g 2 7 ,3 9 4 2 ,8 9 2 7 2 7 2 5 .1 4 % 2 ,1 4 2 2 ,7 4 0 2 1 .8 % Yo rk 4 2 7 ,1 4 0 3 6 ,3 1 1 1 2 ,6 7 2 3 4 .9 0 % 2 8 ,1 0 0 3 7 ,3 2 7 2 4 .7 % So ur ce : U .S . C en su s B ur ea u, A m er ic an C om m un it y S ur ve y, 2 01 1– 2 01 6 . 28 Michele Moser Deegan anD a. lanethea Mathews- schultz NOTES 1. The ACA extends Medicaid coverage to individuals living at 133% of the FPL, but requires states to apply a 5% income disregard in determining eligibility, effectively bring- ing minimum eligibility requirements to 138% of the federal poverty level. 2. In response to mandated Medicaid expansion and to the “individual Mandate” pro- visions of the ACA requiring individuals to obtain health insurance or face a tax penalty, 26 states and the National Association of Independent Businesses sued the federal govern- ment. The states were Alabama, Alaska, Arizona, Colorado, Florida, Georgia, Idaho, Indi- ana, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Nebraska, Nevada, North Dakota, Pennsylvania, Ohio, South Carolina, South Dakota, Texas, Utah, Washington, Wisconsin, and Wyoming. 3. Others include Arkansas, Maine, Oklahoma, Tennessee, and Wyoming. Of these, only Arkansas is reforming Medicaid and it is doing so through a Section 1115 Waiver, rather than the ACA expansion. Pennsylvania is the only mixed or hybrid state to have adopted the ACA Medicaid expansion. 4. A handful of additional states pursued similar state- run privatized alternatives for expanding Medicaid, including Arkansas, Iowa, Michigan, and Tennessee. 5. These individuals are referred to as PCO beneficiaries because they receive care through private managed plans. Eligibility under Corbett’s Private Coverage Program was limited to individuals ages 21–64 with incomes up to 133% of the federal poverty level, including childless adults and those with incomes greater than 33% FPL, which was previously the income cap for Medicaid in Pennsylvania. Existing Medicaid recipients were funneled into one of two new managed plans: a high- risk pool enrolling pregnant women, SSI beneficiaries, and those eligible for Medicare and Medicaid; and a low- risk pool offering more limited medical services. Newly eligible adults not determined to be “medically frail” were enrolled in the Private Coverage option. 6. The CMS project stipulated that cost sharing and premium contributions could not exceed 5% of family income. 7. Marilyn Tavenner, Secretary, Federal Department of Health and Human Services to Beverly Mackereth, Secretary of the Pennsylvania Department of Public Welfare, August 28, 2014. 8. Prior to the ACA, states were already required to provide coverage at higher levels to children and pregnant women. 9. Some 19- and 20- year- old adults without children with incomes up to 33% FPL previously were eligible for coverage. 10. Press Release 2015. 11. One limitation is that for the purposes of Medicaid eligibility in the state of Penn- sylvania, adults are considered individuals ages 21–64. The Census data on poverty and the uninsured, however, defines adults as those ages 18–64. 12. We do not estimate it here, but it is important not to underappreciate the effects of Obamacare and Medicaid expansion on individuals previously eligible for but nonetheless un- enrolled in Medicaid. 13. Prior to implementation of the ACA, county and municipal health departments could provide primary care services not available through state district offices, such as immunizations, mammograms, and dental services. The Limits of Medicaid Reform in Pennsylvania 29 REFERENCES Beeler, Carolyn. 2013. “Corbett Rejects Obamacare Medicaid Expansion for Penn- sylvania.” Newsworks, February 5. Available at www.newsworks.org/index.php/ local/healthscience/50558-corbett-rejects-obamacare-medicaid-expansion-for -pennsylvania. Accessed June 24, 2016. 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History.” MSBC.com, September 13. Available at http://www.msnbc.com/hardball/ corbett-could-be-first-governor-lose-re-el. Accessed June 22, 2016. Ledebur, Larry C., and William R. Barnes. 1993. All in It Together: Cities, Suburbs, and Local Economic Regions. Washington, DC: National League of Cities. Luo, Wei. 2004. “Using a GIS- based Floating Catchment Method to Assess Areas with Shortage of Physicians.” Health and Place 10: 1–11. Lynch, John W., Richard D. Cohen, Katherine E. Heck, Jennifer L. Balfour, and Irene H. Yen. 1998. “Income Inequality and Mortality in Metropolitan Areas of the United States.” American Journal of Public Health 88 (7): 1074–1080. Massachusetts Public Health Regionalization Project. 2016. Available at www.bu.edu/ regionalization/. Accessed June 30, 2016. Massachusetts Public Health Regionalization Working Group. 2009. “Massachusetts Pub- lic Health Regionalization Project Status Report.” Mathews, A. 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Pennsylvania Association of Community Health Centers. 2015. “Community Health Cen- ters Pennsylvania Directory.” PolicyLink. 2002. “Promoting Regional Equity: A Framing Paper.” Prepared by PolicyLink for Promoting Regional Equity: A National Summit on Equitable Development, Social Justice, and Smart Growth, November 17–19, Los Angeles, CA. http://www.msnbc.com/hardball/corbett-could-be-first-governor-lose-re-el http://www.msnbc.com/hardball/corbett-could-be-first-governor-lose-re-el http://www.lehighvalleyresearch.org http://www.lehighvalleyresearch.org http://www.lehighvalleyresearch.org http://www.health.state.mn.us/divs/opi/gov/context/ http://www.health.state.mn.us/divs/opi/gov/context/ http://www.mcall.com/news/local/elections/mc-pa-governor-election-wolf-corbett-20141104-story.html http://www.mcall.com/news/local/elections/mc-pa-governor-election-wolf-corbett-20141104-story.html The Limits of Medicaid Reform in Pennsylvania 31 Press Release. 2015. “150,000 Additional Pennsylvanians Enrolled in Governor Wolf ’s Medicaid Expansion Plan,” Office of Governor Tom Wolf, July 22. Ramsay, David. 2015. “Red States Are Reinventing Medicaid to Make It More Expensive and Bureaucratic.” New Republic, January 18. Rusk, David R. 2003. “Cities without Suburbs: A 2000 Census Update,” 3rd ed. Washing- ton, DC: Woodrow Wilson Center. Salinsky, Eileen. 2010. “Governmental Public Health: An Overview of State and Local Public Health Agencies.” National Health Policy Forum, Background Paper, No. 77. Savitch, H. V., D. Collins, D. Sanders, and J. P. Markha. 1993. “Ties That Bind: Central Cities, Suburbs and the New Metropolitan Region.” Economic Development Quarterly 7 (4): 341–357. Savitch, H. V., and Ronald K. Vogel. 2000. “Paths to New Regionalism.” State and Local Government Review 32 (3): 158–168. Schulz, Amy J., David R. Williams, Barbara A. Israel, and Lora Bex Lempert. 2002. “Racial and Spatial Relations as Fundamental Determinants of Health in Detroit.” Milbank Quarterly 80 (4): 677–707. Swanstrom, Todd, Peter Dreier, and John Mollenkopf. 2002. “Economic Inequality and Public Policy: The Power of Place.” City and Community 1 (4): 349–373. Wang, Fahui, and Wei Luo. 2005. “Assessing Spatial and Nonspatial Factors for Health- care Access: Towards an Integrated Approach to Defining Health Professional Short- age Areas.” Health and Place 11: 131–146. Wang, Fahui, and W. William Minor. 2002. “Where the Jobs Are: Employment Access and Crime Patterns in Cleveland.” Annals of the Association of American Geographers 92 (3): 435–450. Wenner, David. 2014. “Corbett Claims ‘Historic’ Achievement in Pa. Plan to Use Obama- care Expansion Funds.” PennLive, August 28. Available at www.pennlive.com/ midstate/index.ssf/2014/08/pennsylvania_corbett_obamacare.html. Accessed June 24, 2016. Michele Moser Deegan, PhD, is an associate professor and the chair of the Political Sci- ence Department at Muhlenberg College. She is also the founding director of the Lehigh Valley Research Consortium. Her research and publications focus on issues of inequality at the local level, particularly in the areas of education and health policy. Her publica- tions include articles in the Journal of Urban Affairs, Public Administration Review, and Educational Evaluation and Policy Analysis and multiple research studies of the Lehigh Valley region of Pennsylvania. a. lanethea Mathews-s chultz, PhD, is an associate professor of political science at Muhlenberg College, where she teaches classes on American politics, gender and public policy, citizenship, and political institutions. As an independent researcher affiliated with the Lehigh Valley Research Consortium, she has conducted several regional studies of community health, focusing on access and equity issues in health and well-b eing. Her recent work has been published in Political Research Quarterly and Progress in Community Health Partnerships: Research, Education, and Action. http://www.pennlive.com/midstate/index.ssf/2014/08/pennsylvania_corbett_obamacare.html http://www.pennlive.com/midstate/index.ssf/2014/08/pennsylvania_corbett_obamacare.html Structure Bookmarks The Limits of Medicaid Reform in Pennsylvania Seeking Regional Solutions to Health Challenges in Pennsylvania