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During economic downturns, states may struggle to finance Medicaid, a federal-state health financing program for certain low-income individuals. States receive federal matching funds for their Medicaid programs according to a statutory formula based on each state's per capita income (PCI) in relation to national PCI. The number of individuals eligible for Medicaid can increase during downturns as a result of rising unemployment. GAO previously reported that any federal assistance to respond to downturns should be well-timed and account for each state's fiscal circumstances. GAO was asked to consider strategies to help states offset increased Medicaid expenditures in the event of future economic downturns. GAO analyzed policy proposals and federal and state strategies to cope with downturns to identify and develop three potential strategies. GAO explored (1) targeting assistance to states most affected by a downturn, (2) using 2 instead of 3 years of PCI data to compute federal matching rates to more accurately reflect states' economic circumstances, and (3) giving states the option to obtain assistance based on their own determination of need. GAO discussed the strategies with experts, identified design considerations, and analyzed each strategy's potential effects. The Department of Health and Human Services received a draft of this report and did not comment.

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