50-State Constraint Reference

Document Purpose

#

This reference table integrates the six primary constraint dimensions that shape RHTP implementation outcomes across all 50 states. It is designed as a single-source lookup for production of Articles 3B through 3E and the Series 3 Synthesis, and as a standing reference for cross-series analysis throughout the RHTP project.

Each row represents one state. Each column represents a dimension that either constrains or enables implementation. The combination of dimensions across a row constitutes a state’s constraint profile, the analytical basis for cluster assignment in Article 3B and strategic choice analysis in Article 3E.

This document does not include qualitative analysis. Interpretation of patterns, cluster assignments, and implications appear in the Series 3 articles. This table provides the data foundation for that analysis.

Data Sources and Methodology

#

Column 1, FY2026 RHTP Award: CMS cooperative agreement awards announced December 29, 2025. Exact figures from U.S. Chamber of Commerce publication of CMS data. Sourced via RHTP 2-TD-A and 5-TD-A.

Column 2, Rural Population: U.S. Census Bureau American Community Survey 5-year estimates (ACS 2019-2023). Figures rounded to nearest thousand where source data uses rounded estimates. Sourced via RHTP 5-TD-A.

Column 3, RHTP Per Rural Resident: Calculated as FY2026 annual award divided by rural population count. Represents annual federal investment per rural resident, not 5-year total.

Column 4, 5-Year RHTP Total: FY2026 annual award multiplied by 5. Assumes constant annual award; CMS may adjust in subsequent fiscal years based on performance scoring.

Column 5, Medicaid Cut (10-Year): KFF allocation of CBO’s $911B federal Medicaid spending reduction across states, midpoint estimate. Source: Euhus, Rhiannon, et al., KFF, July 23, 2025. Underlying data from Datawrapper dataset data-36eMx.csv, same publication.

Column 6, % of Baseline: State’s 10-year Medicaid cut as percentage of projected federal Medicaid baseline spending 2025-2034. KFF calculation.

Column 7, Medicaid Math Ratio: State’s 10-year Medicaid cut divided by 5-year RHTP total. Expresses how many dollars of Medicaid cuts accompany each RHTP dollar. See methodology note in main precursor document.

Column 8, Expansion Status: ACA Medicaid expansion adoption as of July 4, 2025 (OBBBA enactment). Sources: KFF Status of State Medicaid Expansion Decisions, September 29, 2025.

Column 9, Authority Gap: Lead agency decision authority assessment from RHTP 5-TD-A. Four-tier scale: Low, Low-Moderate, Moderate, Moderate-High, High. Reflects distance between formal accountability and actual decision authority.

Column 10, Primary Cut Mechanism: Dominant provision driving state’s Medicaid spending reduction, derived from KFF provision composition chart (July 23, 2025 analysis). Abbreviations: WR = work requirements, PT = provider tax restrictions, SDP = state-directed payment limits.

Column 11, 2026 Gubernatorial Election: States with scheduled gubernatorial elections in 2026. Political continuity risk indicator for five-year implementation programs.

Complete 50-State Reference Table

#

Quick-Reference Derived Tables

#

By Medicaid Math Ratio (Descending)

#

For Article 3C production and Medicaid Math narrative. Shows states in order of fiscal imbalance severity.

By Per-Capita RHTP Allocation (Descending)

#

For Article 3B cluster assignment and scale penalty analysis. Shows the full range of per-resident investment across states.

Range: $63/resident/year (North Carolina) to $990/resident/year (Alaska), excluding Rhode Island ($6,248) as an outlier driven by its 25,000-person rural population. The 15-fold gap between North Carolina and Alaska, both large RHTP recipients by total award, represents the scale penalty at its most extreme.

Non-Expansion States: Isolated View

#

For analysis of the non-expansion tier, which faces smaller Medicaid cuts but also lacks ACA billing sustainability pathways for RHTP programs.

Note: Florida and Georgia appear here but have distinct profiles. Florida is fully non-expansion with large population, Georgia implemented partial expansion through Pathways waiver. Wisconsin uses a 1115 waiver to provide comparable coverage; KFF includes Wisconsin in work requirement exposure given its waiver structure.

States with High or Very High Authority Gaps

#

For Article 3B cluster analysis. These states face compounded implementation risk: adverse fiscal conditions combined with organizational fragmentation.

Mississippi and South Carolina are the two states with High authority gap ratings. Both are non-expansion states, meaning their sustainability pathways for RHTP programs are further constrained. Mississippi’s rural population of 1.6M at $129/resident positions it in the constrained per-capita tier despite a relatively low Medicaid Math ratio.

Structural Patterns: Five Observations for Series 3 Analysis

#

Observation 1: The scale penalty is not marginal. The gap between North Carolina at $63/resident and Alaska at $990/resident is not a rounding difference; it is a 15-fold difference in annual investment per rural person. RHTP’s formula creates genuinely different program environments within the same grant program.

Observation 2: High ratios do not cluster in the same states as high authority gaps. Illinois (47.1:1 ratio, Moderate-High gap) is the most striking overlap, but most high-ratio states have Low or Moderate authority gaps, meaning the fiscal constraint is real but the organizational capacity to respond is present. This is a critical nuance: the crisis is financial, not primarily organizational.

Observation 3: Non-expansion states show divergent profiles. Wyoming (0.2:1 ratio, Low gap, $554/resident) and Texas (22.2:1 ratio, Moderate-High gap, $65/resident) are both non-expansion states but occupy opposite ends of every dimension. Non-expansion is not a uniform constraint category.

Observation 4: The provider-tax and SDP-dominant states face a qualitatively different threat. Indiana (PT+SDP dominant, 18.8:1), Pennsylvania (PT+SDP dominant, 47.3:1), and New Hampshire (PT+SDP dominant, 2.3:1) face rate reductions on existing volume rather than enrollment decline. RHTP payment model innovation applies more directly here than enrollment stabilization strategies. These states need different technical assistance than work-requirement-dominant states.

Observation 5: Political continuity risk concentrates in the moderate-ratio tier. The 14 states with 2026 gubernatorial elections include Florida (12.9:1), Georgia (7.0:1), Minnesota (19.8:1), Oregon (22.2:1), Washington (40.6:1), West Virginia (5.4:1), and Wisconsin (6.6:1). High-ratio states in this group face both fiscal instability and leadership transition risk within the first two years of RHTP implementation.