AARP Public Policy Institute INSIGHT on the Issues The State of Measurement of Respite Care Ari Houser Kathleen Ujvari AARP Public Policy Institute Produced by the AARP Public Policy Institute with support from The SCAN Foundation and The Commonwealth Fund Respite care addresses one of the most pressing needs of family caregivers— temporary relief from caregiving tasks. It is the service strategy most commonly offered to support family caregivers and is available in all 50 states. However, definitions of respite vary among programs and states, and quality and completeness of reported data are often lacking, making rigorous comparison among states impossible. This report describes the main sources of publicly funded respite care and presents data for the year 2007. Respite care addresses one of the most a measure that was complete, accurate, pressing needs of family caregivers— and comparable across states. temporary relief from caregiving tasks. Prior research has shown that respite is However, the data obtained for the year the service strategy most commonly 2007 (the most recent for which data offered to support family caregivers and were available during the production of is available in all 50 states, yet the the Scorecard) provide perhaps the most amount of respite offered varies complete compilation of respite substantially from state to state and spending across all three major funding among programs within states. 1 sources: services provided through Medicaid home and community-based The 2011 report Raising Expectations: A services (HCBS) waivers and other State Scorecard on Long-Term Services HCBS programs, state-funded single- and Supports for Older Adults, People and multiservice HCBS programs, and with Physical Disabilities, and Family the National Family Caregiver Support Caregivers (the Scorecard), evaluated Program, administered by the U.S. state long-term services and supports Administration on Aging. 3 The data are (LTSS) system performance on four presented and briefly discussed in this dimensions, including support for family Insight on the Issues. caregivers. 2 As contributing authors to the Scorecard, produced by the AARP Medicaid Public Policy Institute and funded by The Commonwealth Fund and The Two sources were used to collect data on SCAN Foundation, we were initially Medicaid respite spending in 2007. The optimistic about including a measure of first was an analysis of claims data using publicly funded respite in each state. the Medicaid Analytic Extract (MAX) However, we were not able to construct database, by Mathematica Policy The State of Measurement of Respite Care Research (MPR). Building on work for table 1 for amounts for each state from the HCBS taxonomy that is under both sources. Most of the $40 million development, MPR, as a subcontractor difference between sources can be to the Scorecard project, identified attributed to Kentucky, which reported six national and a large number of state- $38 million in respite spending on the specific service codes for respite and 372 forms (likely an error, as it would calculated the total respite spending in represent more than half of the state’s each state on waiver programs, personal total aged/disabled waiver spending) but care, long-stay home health, and other had less than $1 million in spending in HCBS, excluding spending for Medicaid the claims data. beneficiaries under age 21and those under age 65 who also used institutional Other than Kentucky, most states with services or were enrolled in waivers for large amounts of Medicaid respite the mental retardation/developmental spending showed approximate disability or mental illness populations. agreement between sources. Perfect agreement is not to be expected. In The second Medicaid data source is addition to normal intersource spending reported by states to the differences that are seen in Medicaid Centers for Medicare & Medicaid data, definitional differences have a Services on form 372 for 1915(c) waiver variable impact, depending on the programs. Total respite spending for structure of the state’s Medicaid aged and disabled waivers, by state, program. A state that covers respite as a were provided to the authors by Terence state plan service may have higher Ng at the University of California at San respite spending in the claims data Francisco. The core service definition analysis than on the 372 forms; for a for respite is “Services provided to state in which service codes are hard to participants unable to care for classify, or in which an aged/disabled themselves that are furnished on a short- waiver provides respite to caregivers of term basis because of the absence or people younger than 21, the amount need for relief of those persons who reported on the 372 forms may be normally provide care for the participant. higher. Federal financial participation is not to be claimed for the cost of room and State-Funded Services board except when provided as part of respite care furnished in a facility Robert Mollica, then with the National approved by the State that is not a Academy of State Health Policy, private residence.” 4 surveyed state-funded HCBS programs, including total spending and services States are free to supplement or modify covered (out of 16 categories, including the core definition as appropriate to respite), for a 2009 AARP Public Policy incorporate specific service elements. Institute report. 5 The survey defined This analysis would only capture respite respite as “short-term temporary services provided through the waivers, assistance provided in the home during and would not include respite provided the absence of the primary caregiver or as a state plan service. to relieve the caregiver; other caregiver support.” The total amount of Medicaid respite spending was $190 million according to One major challenge with these data is the 372 reports, and $150 million that only funding for single-service according to the claims analysis. See respite programs can be tallied; there 2 The State of Measurement of Respite Care was about $20 million in single-service ■ Adult family members or other respite spending in 12 states in 2007 informal caregivers age 18 and older (another $4.5 million in two states could providing care to individuals be estimated based on spending in 60 years of age and older; previous years). ■ Adult family members or other Multiservice programs, however, make informal caregivers age 18 and older up the bulk of state general revenue providing care to individuals of any HCBS spending (almost 90 percent of age with Alzheimer’s disease and $1.2 billion in total spending across all related disorders; the states). Multiservice programs with ■ Grandparents and other relatives (not respite as a covered service had a total of parents) 55 years of age and older $822 million in expenditures in providing care to children under the 32 states. The amount going to respite age of 18; and could only be estimated in 2 of these states; for the other 30 states, there was ■ Grandparents and other relatives (not no basis in the survey data to estimate parents) 55 years of age and older the proportion going to respite. If even providing care to adults age 18 to 59 5 percent of expenditures in multiservice with disabilities. programs that cover respite goes to The basic definition of respite care is respite, it would triple the amount of given in the Older Americans Act state money identified; thus it is likely (OAA) as “respite care to enable that the majority of state-funded respite caregivers to be temporarily relieved is missing from this data source. from their caregiving responsibilities.” 6 Total program expenditures for single- At the federal level, this definition is service respite programs and intended to serve as a guide for states; multiservice programs that include the states are responsible for defining respite are shown in table 2. Two states, respite care and determining the scope of Alaska and Michigan, had single-service services that are deemed to be respite programs in 2002 that were aggregated care. AoA does not dictate the type of into a multiservice program in 2007. services that should be considered Assuming the relative amount of respite care. As a result, adult day spending by service can be held services, in-home care, overnight care, constant, respite spending can be and away camp services may or may not estimated for these states for 2007 (see be considered forms of respite care, table 3). depending upon the state. 7 AoA publishes data that states report on U.S. Administration on Aging how much NFCSP (Title III(e) of the (National Family Caregiver OAA) money was spend on respite; AoA Support Program) also encourages states to report all respite spending for those eligible under The U.S. Administration on Aging Title III(e). NFCSP respite spending, (AoA) administers the National Family and other respite spending reported to Caregiver Support Program (NFCSP), AoA, is shown in table 4. In 2007, which provides grants to states and NFCSP respite spending totaled territories to fund a range of supports for $53 million, and other reported spending family caregivers, including respite. The $84 million. The State Program Reports following are eligible caregiving from which these data are drawn are not populations: 3 The State of Measurement of Respite Care intended to be a fiscal accounting respite data, we were not able to system. In addition, the Title III(e) construct a measure that was complete, eligible population is not necessarily the accurate, and comparable across states. same as that eligible under Medicaid However, the data collected may be waivers or state-funded programs. As useful as a noncomparative resource, and table 5 shows, the “other spending” to identify the current capacity to reported to AoA typically does not measure respite across states. match respite expenditures taken from Medicaid and state-funded sources. Table 6 shows total respite spending from these three sources, divided by the Total Respite and Discussion estimated number of caregivers in each state. 8 These data are not complete or Because of differences in definitions of comparable between states, and despite respite between states (each source gives the rank column in the table (for only a broad definition, with the state illustrative purposes only), should not be determining which services count as used to compare or rank states. If data respite), the differences in Medicaid can be made consistent and reliable, this spending on respite between sources, or a similar measure would be a useful and the incompleteness of state-funded indicator of LTSS system performance. Endnotes 1 Lynn Friss Feinberg, Sandra L. Newman, Leslie Gray, Karen N. Kolb, and Wendy Fox-Grage. The State of the States in Family Caregiver Support: A 50-State Study. Family Caregiver Alliance, November 2004. 2 Susan C. Reinhard, Enid Kassner, Ari Houser, and Robert Mollica. Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers. Washington, DC: AARP Public Policy Institute, The Commonwealth Fund, The SCAN Foundation, September 2011. 3 Feinberg et al. (2004) also collected state-by-state respite spending for many programs for years 2001–2003. 4 Centers for Medicare & Medicaid Services. Application for a §1915(c) Home and Community-Based Waiver [Version 3.5]: Instructions, Technical Guide and Review Criteria. 2008. 5 Robert L. Mollica, Kristin Simms-Kastelein, and Enid Kassner. State-Funded Home and Community- Based Services Programs for Older Adults. Washington, DC: AARP Public Policy Institute,April 2009. 6 Title III, Section 373. Older Americans Act of 1965, as amended in 2006 (Public Law 109-365). 7 Not all such services can be considered respite, however. For example, adult day services used Insight on the Issues 63, April, 2012 by an older person who does not have a family caregiver would not be considered respite, as the AARP Public Policy Institute service does not provide temporary relief from 601 E Street, NW, Washington, DC 20049 caregiving responsibilities. www.aarp.org/ppi 8 Ari Houser and Mary Jo Gibson. Valuing the 202-434-3890, ppi@aarp.org Invaluable: The Economic Value of Family © 2012, AARP. Caregiving, 2008 Update. Washington, DC: Reprinting with permission only. AARP Public Policy Institute, November 2008. 4 Table 1 Medicaid Respite Spending, 2007 Claims Analysis Waiver Reports Claims Analysis Waiver Reports State (MAX) (Form 372) State (MAX) (Form 372) U.S. Total $149,664,692 $190,304,314 Missouri $29,040,752 $29,191,151 Alabama $6,420,252 $8,527,653 Montana $134,570 $137,112 Alaska $2,856,030 $2,742,909 Nebraska $69,175 $1,012,064 Arizona NA $0 Nevada $84,335 $112,472 Arkansas $13,849,409 $11,702,942 New Hampshire $118,655 $136,287 California $1,736,942 $1,244,310 New Jersey $569,606 $603,536 Colorado $843,253 $822,923 New Mexico $70,595 $1,603,297 Connecticut $477,578 $375,770 New York $342,303 $331,860 The State of Measurement of Respite Care Delaware $494,446 $340,661 North Carolina $553,725 $429,399 District of Columbia $35,617 $572,459 North Dakota $312,037 $196,601 Florida $12,728,013 $14,549,802 Ohio $176,114 $217,200 Georgia $147,833 $1,575,550 Oklahoma $390,948 $657,257 5 Hawaii $8,997 $596,845 Oregon $373,461 $0 Idaho $289,091 $302,079 Pennsylvania $7,464,582 $6,981,660 Illinois $4,484 $0 Rhode Island $0 $0 Indiana $5,450,020 $8,318,009 South Carolina $167,658 $84,046 Iowa $3,025,978 $8,016,926 South Dakota $6,897 $0 Kansas $11,120 $0 Tennessee $567,895 $362,844 Kentucky $817,787 $37,377,908 Texas $8,916,129 $3,763,216 Louisiana $2,201 $0 Utah $312,893 $197,814 Maine NA $439,199 Vermont $47,655 $0 Maryland $27,619 $232,764 Virginia $26,519,303 $30,338,511 Massachusetts $4,400 $494,457 Washington $4,628,470 $0 Michigan $8,503,536 $7,484,365 West Virginia $7,382 $0 Minnesota $1,273,072 $3,551,180 Wisconsin $5,946,119 $1,396,469 Mississippi $3,702,499 $3,204,875 Wyoming $133,256 $77,932 Note that there are definitional differences between the claims analysis and waiver reports, as well as between states. Data may be incomplete. Data may not be comparable across states and should not be used for comparative purposes. Table 2 Respite Spending in State-Funded Programs, 2007 Multiservice Multiservice Single-Service Programs Covering Single-Service Programs Covering State Respite Programs Respite State Respite Programs Respite U.S. Total $20,415,988 $822,497,181 Missouri $0 $11,024,569 Alabama $0 $0 Montana $0 $0 Alaska $0 $2,131,985 Nebraska $810,000 $0 Arizona $0 $16,217,498 Nevada $0 $1,941,798 Arkansas $0 $0 New Hampshire $0 $0 California $333,000 $8,433,000 New Jersey $5,359,000 $10,000,000 Colorado $0 $7,000,000 New Mexico $0 $21,635,061 The State of Measurement of Respite Care Connecticut $1,288,040 $39,328,092 New York $0 $72,365,184 Delaware $110,000 $0 North Carolina $0 $29,931,813 District of Columbia $0 $16,784,032 North Dakota $0 $7,328,250 Florida $0 $67,240,223 Ohio $4,085,888 $10,630,988 6 Georgia $0 $14,816,932 Oklahoma $0 $0 Hawaii $0 $0 Oregon $0 $6,000,000 Idaho $0 $0 Pennsylvania $0 $171,018,000 Illinois $0 $0 Rhode Island $0 $0 Indiana $0 $48,765,643 South Carolina $0 $1,248,208 Iowa $0 $12,652,350 South Dakota $692,400 $0 Kansas $0 $6,783,690 Tennessee $0 $0 Kentucky $1,859,875 $17,586,230 Texas $0 $4,767,229 Louisiana $0 $0 Utah $0 $3,977,295 Maine $589,324 $6,337,531 Vermont $0 $0 Maryland $0 $0 Virginia $0 $5,357,554 Massachusetts $0 $131,319,422 Washington $3,633,000 $8,786,000 Michigan $0 $12,954,460 West Virginia $795,000 $0 Minnesota $860,461 $44,983,000 Wisconsin $0 $0 Mississippi $0 $0 Wyoming $0 $3,151,144 Note that there are definitional differences across states, and the amount of respite in multi-service programs cannot be estimated from the available data. Data may be incomplete. Data may not be comparable across states and should not be used for comparative purposes. Table 3 Estimated Respite Spending in Multiservice State Programs for Two States Single-Service Multiservice Estimated Spending Service Spending (2002) Spending (2007) by Service (2007) Alaska Care Coordination $962,900 $1,411,405 $2,131,985 Respite $491,600 $720,580 Michigan Adult Day Care $2,135,372 $2,430,409 Homemaker $3,305,245 $3,761,920 The State of Measurement of Respite Care $12,954,460 In-Home Respite $3,277,041 $3,729,819 Personal Care $2,664,208 $3,032,313 7 Table 4 National Family Caregiver Support Program (OAA Title III(e)) Respite Spending and Other Respite Spending Reported to AoA, 2007 Other Other Spending Total Respite Spending Total Respite OAA Title Reported to Reported to Reported to Reported to State III(e) AoA AoA State OAA Title III(e) AoA AoA U.S. Total $53,468,187 $84,056,663 $137,524,850 Missouri $1,034,829 $81,723 $1,116,552 Alabama $891,985 $307,378 $1,199,363 Montana $199,321 $283,998 $483,319 Alaska $167,450 $86,150 $253,600 Nebraska $419,802 $87,002 $506,804 Arizona $928,188 $1,562,043 $2,490,231 Nevada $330,324 $0 $330,324 Arkansas $676,686 $347,770 $1,024,456 New Hampshire $155,227 $0 $155,227 California $4,081,864 $3,232,506 $7,314,370 New Jersey $1,696,093 $1,153,462 $2,849,555 The State of Measurement of Respite Care Colorado $713,999 $511,374 $1,225,373 New Mexico $558,418 $1,442,426 $2,000,844 Connecticut $587,427 $224,528 $811,955 New York $4,259,516 $1,865,247 $6,124,763 Delaware $353,066 $110,000 $463,066 North Carolina $1,389,702 $1,127,606 $2,517,308 District of Columbia $54,602 $71,073 $125,675 North Dakota $331,274 $153,743 $485,017 $5,909,377 $18,267,424 $24,176,801 $2,074,246 $81,354 $2,155,600 8 Florida Ohio Georgia $719,951 $5,153,393 $5,873,344 Oklahoma $662,092 $164,648 $826,740 Hawaii $351,424 $53,421 $404,845 Oregon $108,954 $6,900 $115,854 Idaho $243,105 $60,176 $303,281 Pennsylvania $4,744,473 $1,590,599 $6,335,072 Illinois $1,240,599 $94,157 $1,334,756 Rhode Island $290,000 $0 $290,000 Indiana $1,096,611 $390,900 $1,487,511 South Carolina $856,460 $477,123 $1,333,583 Iowa $338,435 $265,694 $604,129 South Dakota $315,742 $129,967 $445,709 Kansas $405,892 $389 $406,281 Tennessee $1,689,722 $677,452 $2,367,174 Kentucky $621,769 $361,003 $982,772 Texas $2,297,369 $27,186,631 $29,484,000 Louisiana $1,019,062 $380,407 $1,399,469 Utah $292,325 $178,943 $471,268 Maine $293,972 $89,557 $383,529 Vermont $80,559 $256,277 $336,836 Maryland $751,791 $352,519 $1,104,310 Virginia $1,498,524 $1,691,922 $3,190,446 Massachusetts $401,347 $361,415 $762,762 Washington $676,466 $3,086,994 $3,763,460 Michigan $2,472,878 $8,824,838 $11,297,716 West Virginia $759,225 $489,066 $1,248,291 Minnesota $675,302 $503,558 $1,178,860 Wisconsin $624,001 $88,600 $712,601 Mississippi $954,592 $0 $954,592 Wyoming $172,150 $143,308 $315,458 Note that there are definitional differences across states, and State Program Reports are not meant to be a fiscal accounting system and may be incomplete. Data may not be comparable across states and should not be used for comparative purposes. Table 5 Comparison of Respite Spending Other Than NFCSP Reported to AoA with Medicaid and State-Funded Respite, 2007 Single- Single- Other Service Other Service Spending Medicaid Medicaid State Spending Medicaid Medicaid State State (from AoA) (MAX) (372 forms) Funded State (from AoA) (MAX) (372 forms) Funded U.S. Total $84,056,663 $149,664,692 $190,304,314 $24,866,387 Missouri $81,723 $29,040,752 $29,191,151 $0 Alabama $307,378 $6,420,252 $8,527,653 $0 Montana $283,998 $134,570 $137,112 $0 Alaska $86,150 $2,856,030 $2,742,909 $720,580* Nebraska $87,002 $69,175 $1,012,064 $810,000 Arizona $1,562,043 n/a $0 $0 Nevada $0 $84,335 $112,472 $0 Arkansas $347,770 $13,849,409 $11,702,942 $0 New Hampshire $0 $118,655 $136,287 $0 California $3,232,506 $1,736,942 $1,244,310 $333,000 New Jersey $1,153,462 $569,606 $603,536 $5,359,000 $511,374 $843,253 $822,923 $0 $1,442,426 $70,595 $1,603,297 $0 The State of Measurement of Respite Care Colorado New Mexico Connecticut $224,528 $477,578 $375,770 $1,288,040 New York $1,865,247 $342,303 $331,860 $0 Delaware $110,000 $494,446 $340,661 $110,000 North Carolina $1,127,606 $553,725 $429,399 $0 District of Columbia $71,073 $35,617 $572,459 $0 North Dakota $153,743 $312,037 $196,601 $0 Florida $18,267,424 $12,728,013 $14,549,802 $0 Ohio $81,354 $176,114 $217,200 $4,085,888 Georgia $5,153,393 $147,833 $1,575,550 $0 Oklahoma $164,648 $390,948 $657,257 $0 9 Hawaii $53,421 $8,997 $596,845 $0 Oregon $6,900 $373,461 $0 $0 Idaho $60,176 $289,091 $302,079 $0 Pennsylvania $1,590,599 $7,464,582 $6,981,660 $0 Illinois $94,157 $4,484 $0 $0 Rhode Island $0 $0 $0 $0 Indiana $390,900 $5,450,020 $8,318,009 $0 South Carolina $477,123 $167,658 $84,046 $0 Iowa $265,694 $3,025,978 $8,016,926 $0 South Dakota $129,967 $6,897 $0 $692,400 Kansas $389 $11,120 $0 $0 Tennessee $677,452 $567,895 $362,844 $0 Kentucky $361,003 $817,787 $37,377,908 $1,859,875 Texas $27,186,631 $8,916,129 $3,763,216 $0 Louisiana $380,407 $2,201 $0 $0 Utah $178,943 $312,893 $197,814 $0 Maine $89,557 n/a $439,199 $589,324 Vermont $256,277 $47,655 $0 $0 Maryland $352,519 $27,619 $232,764 $0 Virginia $1,691,922 $26,519,303 $30,338,511 $0 Massachusetts $361,415 $4,400 $494,457 $0 Washington $3,086,994 $4,628,470 $0 $3,633,000 Michigan $8,824,838 $8,503,536 $7,484,365 $3,729,819* West Virginia $489,066 $7,382 $0 $795,000 Minnesota $503,558 $1,273,072 $3,551,180 $860,461 Wisconsin $88,600 $5,946,119 $1,396,469 $0 Mississippi $0 $3,702,499 $3,204,875 $0 Wyoming $143,308 $133,256 $77,932 $0 * Data for Alaska and Michigan were estimated from multiservice programs. Note that there are definitional differences between sources, as well as between states. Data may be incomplete. Data may not be comparable across states and should not be used for comparative purposes. Table 6 Respite Spending per Capita, 2007 (Note that data are incomplete and are not comparable between states and therefore should not be used for comparative purposes) State-Funded Respite National Family Medicaid Respite (Single-Service Caregiver Total Reported Number of Respite per State Spending (MAX) Programs) Support Program Respite Caregivers Caregiver U.S. Total $149,664,692 $24,866,387 $53,468,187 $227,999,266 41,969,267 $5.43 Alabama $6,420,252 $0 $891,985 $7,312,237 817,145 $8.95 Alaska $2,856,030 $720,580 $167,450 $3,744,060 87,023 $43.02 Arizona n/a $0 $928,188 $928,188 847,066 $1.10 Arkansas $13,849,409 $0 $676,686 $14,526,095 477,462 $30.42 The State of Measurement of Respite Care California $1,736,942 $333,000 $4,081,864 $6,151,806 4,032,558 $1.53 Colorado $843,253 $0 $713,999 $1,557,252 572,938 $2.72 Connecticut $477,578 $1,288,040 $587,427 $2,353,045 481,910 $4.88 Delaware $494,446 $110,000 $353,066 $957,512 137,000 $6.99 District of Columbia $35,617 $0 $54,602 $90,219 67,130 $1.34 10 Florida $12,728,013 $0 $5,909,377 $18,637,390 2,769,580 $6.73 Georgia $147,833 $0 $719,951 $867,784 1,360,473 $0.64 Hawaii $8,997 $0 $351,424 $360,421 168,581 $2.14 Idaho $289,091 $0 $243,105 $532,196 209,771 $2.54 Illinois $4,484 $0 $1,240,599 $1,245,083 1,656,749 $0.75 Indiana $5,450,020 $0 $1,096,611 $6,546,631 913,048 $7.17 Iowa $3,025,978 $0 $338,435 $3,364,413 366,620 $9.18 Kansas $11,120 $0 $405,892 $417,012 413,253 $1.01 Kentucky $817,787 $1,859,875 $621,769 $3,299,431 733,518 $4.50 Louisiana $2,201 $0 $1,019,062 $1,021,263 626,271 $1.63 Maine n/a $589,324 $293,972 $883,296 189,758 $4.65 Maryland $27,619 $0 $751,791 $779,410 762,632 $1.02 Massachusetts $4,400 $0 $401,347 $405,747 852,540 $0.48 Michigan $8,503,536 $3,729,819 $2,472,878 $14,706,233 1,440,698 $10.21 Minnesota $1,273,072 $860,461 $675,302 $2,808,835 680,061 $4.13 Mississippi $3,702,499 $0 $954,592 $4,657,091 564,091 $8.26 Missouri $29,040,752 $0 $1,034,829 $30,075,581 864,182 $34.80 Table 6 (continued) State-Funded National Family Respite Caregiver Medicaid Respite (Single-Service Support Total Reported Number of Respite per State Spending (MAX) Programs) Program Respite Caregivers Caregiver Montana $134,570 $0 $199,321 $333,891 130,242 $2.56 Nebraska $69,175 $810,000 $419,802 $1,298,977 218,743 $5.94 Nevada $84,335 $0 $330,324 $414,659 360,810 $1.15 New Hampshire $118,655 $0 $155,227 $273,882 182,713 $1.50 New Jersey $569,606 $5,359,000 $1,696,093 $7,624,699 1,184,904 $6.43 New Mexico $70,595 $0 $558,418 $629,013 285,952 $2.20 New York $342,303 $0 $4,259,516 $4,601,819 2,772,243 $1.66 The State of Measurement of Respite Care North Carolina $553,725 $0 $1,389,702 $1,943,427 1,175,613 $1.65 North Dakota $312,037 $0 $331,274 $643,311 73,964 $8.70 Ohio $176,114 $4,085,888 $2,074,246 $6,336,248 1,655,190 $3.83 Oklahoma $390,948 $0 $662,092 $1,053,040 595,842 $1.77 Oregon $373,461 $0 $108,954 $482,415 461,028 $1.05 11 Pennsylvania $7,464,582 $0 $4,744,473 $12,209,055 1,837,772 $6.64 Rhode Island $0 $0 $290,000 $290,000 147,743 $1.96 South Carolina $167,658 $0 $856,460 $1,024,118 769,708 $1.33 South Dakota $6,897 $692,400 $315,742 $1,015,039 100,235 $10.13 Tennessee $567,895 $0 $1,689,722 $2,257,617 1,129,799 $2.00 Texas $8,916,129 $0 $2,297,369 $11,213,498 3,413,478 $3.29 Utah $312,893 $0 $292,325 $605,218 381,471 $1.59 Vermont $47,655 $0 $80,559 $128,214 83,345 $1.54 Virginia $26,519,303 $0 $1,498,524 $28,017,827 1,168,713 $23.97 Washington $4,628,470 $3,633,000 $676,466 $8,937,936 850,535 $10.51 West Virginia $7,382 $795,000 $759,225 $1,561,607 302,929 $5.16 Wisconsin $5,946,119 $0 $624,001 $6,570,120 522,004 $12.59 Wyoming $133,256 $0 $172,150 $305,406 72,235 $4.23 Note that there are definitional differences between sources, as well as between states. Data are incomplete. Data may not be comparable across states and should not be used for comparative purposes. INSIGHT on the Issues