Feedback about this article is welcome. Please send suggestions or comments to:
MLHhill@vcu.edu
Self-Determination,
Funding Priorities, and WorkWORLD
Benefit and Work Incentive Decision Support System
Spring 2004
Mark L. Hill, P. David Banks, David J. Ruth, Robert M.
Carlson, James L. Troxell
The rhetoric of the last
decade of services for individuals with disabilities has been dedicated to the
advancement of consumer-driven services and the provision of increased consumer
control over the service dollars in order to allow more
self-determination. However, disability
policy is so complex that very few people can effectively make informed decisions
without expert advice; disability policy is not unlike the federal and state
tax codes in this respect. Many expert tax advisors are available to the public
to assist them through the maze, and most of them are fee for service
third-party advisors. People with
disabilities, however, have very few expert advisors to assist them and most
advisors are employed or salaried by the government. It is not a surprise then, that people fear getting bad advice
and/or disclosing information that might harm their benefit situation. Subsequently many people that could be more
self-sufficient do not choose to risk attempts at greater independence.
Can we truly increase
personal self-determination without simplifying policy interpretation and
redesigning the system to focus on building increased individual self-support
and financial independence and growth?
Most people close to our
national disability policy system would say “no”. In this country, unless individuals have the typical incentives
to work–to make higher wages, to save for the future, and to enjoy basic
spending capacity–they are not full participants in society and certainly not
self-determining their own lives. No
matter how hard we try to deny it in our paternalistic disability service
system, personal financial responsibility in this country, at least, is the
“ticket” to self-determination.
Improvements to policies and procedures in the established service
delivery system have been made, but they are nominal in relation to the scope
of the problem and the potential for positive, new possibilities for
self-determination by people with disabilities. Using tools to leverage the transition to self-support and
self-determination is needed. Could
a new emphasis on measurement of self-support outcomes and provision of
WorkWORLD decision support technology, with expert advise when needed, for
individual decision-making help?
Legislators spurred on by
disability advocates and others have courageously started to overhaul the
system with the “Ticket to Work and Work Incentive Improvement Act” of
1999. In fact, many Social Security
Administration (SSA) Work Incentives that could directly empower recipients of
Supplemental Security Income (SSI) and beneficiaries of Disability Insurance
(SSDI) have been available since the 1970's, but only a small percentage of
those that could use them actually do. The
result is unrealized self-support outcomes for people with disabilities. For example, many people receiving SSA
Disability Insurance could benefit from use of a PASS while becoming eligible
for SSI and Medicaid.
Work Incentives* such as PASS
(Plans to Achieve Self Support), Blind Work Expense (BWE), 1619a,b, and IRWE
(Impairment Related Work Expenses), give the individual with a disability the
power to obtain the supports they need to achieve employment, health care, and
net income goals. [click this link to see Description of work incentives at the end of this article.]
Figure 1 shows that
nationally only 3/10ths of 1% of SSI recipients aged 18-64 had active PASSes or
IRWEs in September of 1995.
Figure 2 shows that eight
years later in September of 2003 the number of active PASS plans totaled 1785,
down 84% from the 10,583 total reported in September 1995.
Further, since the total
number of people in September 2003, age 18-64 receiving SSI had grown by about
300,000 since 1995, it becomes very apparent that there have been serious
systemic forces discouraging people from taking advantage of these empowering
programs. People trying to improve the
system know that lack of knowledge about work incentives, lack of accurate
individualized information, and fear of losing benefits because of
demonstrating work capacity are a few of the major causes. The Ticket to Work and Work Incentive
Improvement Act has provided the Social Security Administration a rejuvenated
infrastructure to begin to deal with these barriers. However, to understand the
underutilization of self-support resources, we need to look outside SSA for
other disability system disincentives.
Employment Support Institute
(ESI) staff have extensive experience training people in local communities
about self-support resources. ESI also
responds to help requests by telephone and email. Most direct requests for help come from consumers and family
members; professionals represent about 1/3 of requests. ESI also tracks visitors to its WorkWORLD
website (http://www.workworld.org), and to the Help/Information System there (http://www.workworld.org/wwwebhelp/basic.htm). Figure 3
shows the growth in Help/Information System pages visited through March
2004. There were 18,000 individual
person visits in March, demonstrating how many people are seeking benefit and
work incentive information.
As of March 2004, over 2850
web visitors had signed up for our WorkWORLD email list and requested
notifications about updates to WorkWORLD.
People on the list maintain their own email information, self-selecting
“YES” or “NO” to the question “I would like to be notified of software update
availability.” This web activity and
other ESI staff experiences helping people directly confirm that there is a
substantial need for additional “expert” benefit planning assistance.
We believe the most common
justification from professionals and service providers for lack of work
incentive use is that Work Incentives are perceived by many to be too much trouble to arrange and not worth
the benefits. We need to ask -- Not
worth it for whom; too much trouble,
for whom? From the
paternalistic service system perspective, it is true that the Work Incentives
are not seen as a valuable source of resources for the system to support
individuals with disabilities. The work incentives primarily benefit the
individual with disabilities, adding personal investment possibilities,
increasing net income, reducing the risks of demonstrating work capacity, allowing
greater resources to accumulate, and enabling other individually empowering
outcomes. These outcomes may not be fiscally rewarding for
organizations, but for the individual they may be the most important tool we
have to approach true self-determination through increased self-support and
personal financial investment and growth.
School age work incentive
data is even more dramatic. In
September 2003, there were only five PASS plans active for people under age 18,
in the entire country (SSA, SSI Recipients Who Work Sept 2003). A student age 15 or older who has a work
goal can submit a PASS to SSA. The PASS
specifies the work goal, lists the expenses necessary to achieve it, and
earmarks existing income and/or assets for the expenses. Expenses can include such things as
education, job coaching, assistive technology, and transportation. If SSA approves a PASS, it determines
eligibility for SSI without counting the earmarked funds, which can include
parental income and assets deemed available to the child. SSI benefits then replace most or all of the
earmarked funds. Leaders in Federal, State and local Departments of Education need to
assess their practices that miss helping students with disabilities to access
and use such a powerful work incentive.
Funding should be directed to assist students and families directly to
learn and take advantage of their personal benefits and work incentives.
Who is the Customer?
It is no secret that the
predominant disability system, outside of SSA, currently pays service providers
to support and, in essence, to protect persons with disabilities. The dollars exchanged from the system to
service providers, while never enough, are certainly much more than the small
fees for services paid by the consumers themselves. It is well known that the
primary customer, in non-SSA disability services, is the service system itself, and not the individual with a disability. Most community-based disability service
systems are paternalistic in nature.
The predominant community provider-focused service system, Medicaid, was
legislated to support and protect the greatest number of people at the least
cost and labor possible.
Alternatively, the new world of consumer driven
services and Work Incentives use, while labor intensive at least initially,
benefits the consumer in major life changing ways–but
the beneficial effects on the predominant system or the service provider are
not directly evident. The number of
people achieving self-support as a result of public funds targeted for that
purpose is not currently a common performance outcome. Employment service systems rarely fund
directly the empowerment of the individual by assisting them to understand and
use their individual benefits and work incentives.
Too often, this “chore”
responsibility is passed from one professional to another with most people
afraid to offer advice that might “hurt” the consumer. Current practice shows most professionals
deferring individual and benefit advice to the Benefit Planning Assistance and
Outreach (BPAO) staff funded by the SSA.
Unfortunately, there are far too few of these personnel to give detailed
individually-validated ongoing consumer advice to the millions of unemployed
SSA recipients nationally. Indeed, the
BPAO data system reveals that almost half of the consumers who contact a BPAO
request "Intensive Benefit Support" services (“Benefits Analysis and
Advisement,” “Benefits Support Planning,” and/or “Benefits Management”), yet
more than half of them receive less than three hours and over two-thirds
receive less than four hours total cumulative service time (VCU BARC,
2003). Others close to the consumer
must be added to the list of knowledgeable benefit planners. Teaching paid and unpaid advocates to use
WorkWORLD decision support is one method of adding knowledgeable people;
teaching people how to assist people to use their benefits and work incentives
is one of the primary missing components of a successful employment service
system.
The ESI team believes the major problem defeating the potential
of Work Incentive use today is that the service provider system, outside SSA,
is neither expected to nor rewarded for focusing on empowering individuals to
self-support and to achieve financial and social health. Instead, current fiscal practices make the
primary customer the services funding agency with little emphasis on individual
work incentive based empowerment.
Current fiscal practices value protection, hours worked, and maintaining
the delicate balance of government benefits and service dollars/fees.
Fifty percent of SSI
recipients receiving wages are labeled persons with mental retardation, but
they comprise only about 24% of all SSI recipients aged 18-64. Only 8.7% of 18-64 year old SSI recipients
receive earnings and 55% of those working make under $200 a month, 66% make
under $500 a month (SSA, September, 2003).
The “system” of support
providers are not well rewarded for assisting people to achieve a “living” wage
and higher net income. In fact many
providers, not knowing how much a person can make before they lose benefits,
often advise workers to be cautious about making “too much money.” The
opportunity lost of unrealized income is huge.
Although current legislation allows practices to shift to a more
consumer driven one, for real progress
to be made, Federal, State and local leaders must take risks and explore the
potential of redirecting resources to work incentives and other
self-support/self-determination strategies.
Financial
systems supporting service organizations lack incentives to empower their
consumer customers!
Employment Support Institute
(ESI) staff at Virginia Commonwealth University, while encouraging community
service providers to help people with disabilities use their SSA Work
Incentives, often hear that the purchasing power of individuals is
“insignificant” when compared to that of the State agencies from which they
receive most of their funding. Most
State agencies serving people with disabilities, in turn, get substantial
funding through Federal block grants.
It is not surprising when administrators pay more attention to the big
spending customers (State and Federal purchasers) rather than to a large number
of unknown individuals who each have a relatively small source of SSA or other
consumer-driven funding for employability supports. The individual loses power and ambition, unless individual power and
ambition become the funded goals of the employment service system.
States’ primary disability
service systems, Medicaid and Vocational Rehabilitation, predominantly fund
large service provider organizations where individuals with disabilities are
the indirect secondary customers. To
obtain budget increases, service providers become very responsive to the buyers
that hold the purse strings. In this
customer hierarchy, the satisfaction of big spenders is high on the service
providers' list of priorities, while the satisfaction of the individual with
Work Incentive or other consumer-driven money takes a back seat. The individual’s customer power is devalued
and the person learns little about how to be more self-sufficient, unless
services are funded that put consumers in control of work incentive funds.
Policy makers, parents,
social policy advocates, and people with disabilities often call for "voucher
systems” or consumer-driven budgets, systems in which the individual is given
the funding to purchase needed services and the authority to choose among
providers. Many see consumer-driven
budgets as a way to empower the consumer directly. Many SSA Work Incentives directly empower the recipient, and in
effect are like consumer driven budgets–yet
these incentives are grossly underused (Figure 1, 2, Table 1).
Nationally, the lack of use
of the PASS is a stunning reminder of the lack of investment in self-determination
efforts by state and locally managed disability programs. The number of people in a state with
active PASS and other Work Incentives might be one of the best measures of that
state’s emphasis on self-determination and independence for people with
disabilities. Community service
personnel often report to ESI staff that helping a person to access and manage
their benefits and Work Incentives is a tedious and unrewarding
experience. Delays in helping a person
get needed information; delays in getting agency approvals to activate Work
Incentives, helping the person deal with significant others about the plan, and
time actually helping the person implement and modify the plan long term are
not directly rewarded.
Vocational Rehabilitation,
School Systems, Community Service systems and Federal demonstration funds must
be redirected to pay for the time it takes to assist people directly with
understanding and using their personal benefits and work incentives. Some
Vocational Rehabilitation Counselors allow job coaches, for example, to include
WorkWORLD policy analysis in their supported employment services. Some coaches find it extremely valuable to
bring a new person’s family together to look at the WorkWORLD outputs so that
everyone involved has reduced fears of increased earnings or losing health
care. The successful empowerment of
individuals includes bringing key stakeholders together to achieve a consensus
about the safety and value of achieving higher earnings.
Unfortunately most community
agencies have abandoned helping people use their Work Incentives because they
are not directly funded to perform the service. Individuals do not learn how to persevere to achieve their own personal
resources for self-support. The
individual’s innate ambitions for a higher standard of living are progressively
extinguished.
Although Federal legislation
encourages States to build vendor and service provider heavy systems, there are
solutions. When creative leaders initiate programs that empower the individual
directly they help them achieve a more appropriate “power” balance. Federal, State and local leaders must begin
to invest in self-determination efforts that include assistance with access and
management of benefits and work incentives.
Doing so shifts the locus of control from an over-empowered “system” by
redistributing some of the purchasing power and associated decisions to the
individual with a disability and his/her trusted advisors. New and redesigned strategies and incentive
structures should focus on assisting individuals to achieve their own safe
paths to higher net income and access to health care and not just on building
larger service system infrastructures.
Nerney (2001) points out the value of shifting from a Medicaid provider
system to a more consumer directed system.
The Center for Self-Determination’s (CSD) “Implementing Freedom through
Individual Budget Planning” initiative (Nerney, 2002) teaches consumers and
their trusted advisors to expand options, “stretch the dollar” and generally
benefit the system and person by offering greater flexibility in use of public
monies. Policy exists now, for example,
the Consumer Driven Waiver Services under Medicaid, that would allow state
leadership to shift funds toward individual control. More individuals should be learning how to build their own paths to
self-support and a higher standard of living.
Positive
Outcomes for the Individual
As a service system shifts
more power to assist the individual with their personal benefits and work
incentives, so too should the measures of success shift. New outcome measures might evaluate:
1) Improvements to individual
and family net income (not gross wages);
2) An individual’s and/or
his/her trusted advisor’s knowledge about options and choices;
3) If higher earnings paths
selected are safe and avoid net income cliffs or loss of health care;
4) Work incentive use:
number, duration, value and outcome;
5) The number and quality of
relationships with non-paid significant others;
6) The amount of service
dollars redirected toward assisting people with their personal benefits and
work incentives, (e.g. VR/Medicaid promoting benefit analysis and supporting
use of work incentives under supported employment services)
7) Evidence of potent incentives
for unpaid staff, such as volunteers, family, and friends, to assist a person
to achieve self-determination and self-support, e.g. WorkWORLD training for
consumers directly and for unpaid community members who are likely to advocate
or assist people with disabilities.
The purpose of shifting to
self-support is not to save taxpayers money, although research appears to say
it does (Head, 2001). Rather, the
purpose is to improve people with disability’s quality of life and standard of
living. The Individual gets a “quality”
life and a “ticket to self-determination.”
Positive
Outcomes for the System
As an attempt to estimate a
portion of the opportunity lost for individuals to better control their own
destiny, let’s assume state and local leaders initiate creative strategies that
achieve just 3% of SSI recipients having active PASS plans that set aside an
average of $400 per month for employability supports. The net gain in total resources focused on gainful activity
and self-support would be over $548 million per year. (3,811,479 * .03 * 400 *12 =
$548,852,976). What if we could
achieve 5 or 10% of SSI recipients averaging $500 per month for achieving
employment goals with a PASS? (78% of
PASSes set aside more than $299 per month in September 2003).
Adding 1 billion
dollars for consumers to self-direct plans to achieve self-support is a
realistic goal under current rules and regulations.
The potential infusion of
funds from SSA to individuals to focus on self-support could generate substantial
savings to the taxpayer as well. As
people begin to recognize there are safe ways to achieve independence and a
higher standard of living through earnings and equity growth consumers and
taxpayers alike benefit. Current SSA
rules, when understood fully, allow the great majority of beneficiaries and
recipients to find reasonable paths to independence. Even if people simply achieve “greater” independence (and not
full independence) by achieving earnings and equity growth, both the consumer
and the taxpayer benefit financially.
New awareness and careful management of current SSA rules can break the
long misunderstood potential of SSA beneficiaries and recipients.
The PASS is only one Work
Incentive compatible with self-determination initiatives; there are many. Because
most States lack creative strategies that promote self-determination and use of
individual benefits and Work Incentives, people with disabilities are not
learning to create their own paths to self-support. Taxpayers also miss this opportunity and lose when individuals do
not learn how to self-support themselves or are not allowed to determine their
options. The cost of creating
dependencies for society is an unknown but important factor to consider as
system leaders make their choices about investing in policies and projects that
increase self-determination.
In addition to SSA’s PASS,
there are other consumer-driven programs and Work Incentives, such as the
Consumer Directed Services Waiver under Medicaid, that allow States to balance
the locus of control between system and individual (Nerney 2002). Medicaid Waivers allow States to
"waive" some regulations concerning Medicaid services in order to
experiment with innovative services to a limited number of people.
On May 9, 2002, as a part of
President George W. Bush's "New Freedom Initiative," the Department
of Health and Human Services (HHS) issued a press release describing the
unveiling of two new waiver templates that promise to help states better use
the Medicaid program to enable people with disabilities to choose services in
their own homes and communities. HHS
Secretary Thompson announced that HHS is making information on available
technical assistance on community-integration issues more readily accessible
through a new Web-based resource.
HHS's new "Independence
Plus" waiver templates give states tools to create programs that will
allow people with disabilities and their families to decide how best to plan,
obtain and sustain community-based services, placing control into the hands of
the people using the services.
The electronic templates
provide guidance to states on how to develop these programs within existing
federal requirements using a streamlined application process, which will
ultimately result in faster federal approval of state proposals. Similar programs have been shown to promote
cost-effective and flexible solutions for care while meeting the individual
needs of people receiving services.
The waiver templates
recognize the essential role of the family or individual in planning for and
purchasing health care services while, in many cases, delaying placing the
individual in an institution or other high-cost out-of-home facility. The templates fulfill just one of the commitments
that HHS made to promote community integration in the report "Delivering
on the Promise," which Secretary Thompson delivered to the President on
behalf of nine federal agencies in March 2002.
The templates were developed
by HHS' Centers for Medicare & Medicaid Services (CMS), the federal agency
that administers the federal-state Medicaid program. More information (including the actual templates) is available
at http://cms.hhs.gov/independenceplus/.
Housing rent subsidies,
1619(a,b), Food Stamps, and the Student Earned Income Exclusion are other
resources that the individual might access.
The first important data set to emerge from the self-determination
movement was compiled by Michael Head, Michigan's self-determination project
manager (Head, M., 2001). Head's
analysis of the pre and post "costs" associated with 285 individuals
who moved into a self-determination approach from typical human services is
compelling: $694,663 was "saved" over pre self-determination
expenditures. Head's analysis also
noted that the higher the previous "cost" for an individual the more
the savings.
Our State and Federal support
systems must pay more attention to earnings and Work Incentive based solutions,
shifting Medicaid funding to consumer directed services, and helping people
access other individual resources to foster greater self-sufficiency instead of
continuously expanding top down provider dependencies. Strategies
for simplifying complex policies and providing knowledge based decision
supports should become part of the State’s arsenal for improvement.
Overhauling
the paternalistic system: Start with a Performance and Outcome Measurement
System Focused on Increasing Personal Financial and Social Health
Tight State budgets for
employment supports should create a growing awareness of these
individually-accessed resources. The
untapped potential for assisting people to achieve higher net income and
self-support should prompt state and local leaders to implement strategies
which promote these self-determination options. Although current legislation (TWWIIA, 1999) is designed to
enhance and improve SSA Work Incentives, State, Federal, and local initiatives
are a long way from achieving even 1% of SSI recipients using PASS. SSA’s “Ticket to Work” program rewards both
the person with a disability and an employment service provider, an Employment
Network (EN), for collaborating to achieve at least Substantial Gainful
Activity (SSA Handbook, 2004 web version).
However, unless state and local
leaders initiate concurrent and substantial self-determination efforts that
include assistance to access and manage the
individual’s benefits and Work Incentives, the “Ticket” program may become
yet another underutilized Work Incentive.
State agencies must recognize that the SSA BPAO system is inadequate to
meet the level of need for individualized planning and ongoing support of
consumer self support skills.
To reduce a person’s fear of
losing benefits they need a comprehensive assessment of their current policy
situation and clear steps to a more independent future. When the person chooses the steps and is
confident the steps are safe, independence becomes much more likely. If
Employment Networks (EN) receiving tickets or the individual providing a ticket
do not fully agree on a safe path to independence, both parties will likely not
achieve the full benefit that is possible under the aggressive Ticket to Work
legislation.
The actual use of empowering
benefits and work incentives and consumer driven budgets can be tracked to
measure how well Federal, State and local agencies are doing on the
self-determination front. Nerney (1998)
maintains that self-determination is dependent on four basic principles: freedom to develop a personal life plan,
authority to control a targeted sum of resources, support to obtain personal
goals, and responsibility for contributing to one's community and using public
dollars wisely. Principles of
self-determination establish that people with disabilities are the planners and
decision-makers in all daily living activities, such as working and taking
financial control of service resources and personal income (Southern
Collaborative on Self-Determination, 1997).
Recent data on PASS use helps
to show both the future potential and the current lack of investment in helping
individuals become more self-sufficient.
Table 1 shows Active PASS use by State.
The states are sorted by percent of SSI recipients age18-64 with an
active PASS. Detailed descriptions of
the Work Incentives can be found at the end of this article in the “Description of Work Incentives” section.
Table 1:
Utilization of PASS by State sorted by Percent of SSI 18-64 with an Active PASS
|
|
STATE/DC
|
Active Pass
Plans Sept. 2001
|
Active PASS
Plans Sept. 2003
|
Total SSI 18-64
2003
|
Percent working
2002
|
Percent Working
2003
|
Percent with
PASS 2001
|
Percent with
PASS 2003
|
Change % of all
18-64 with PASS 2001-2003
|
|
1
|
Montana
|
20
|
29
|
10499
|
17.64%
|
16.33%
|
0.195%
|
0.276%
|
41.5%
|
|
2
|
Vermont
|
20
|
15
|
9044
|
13.26%
|
12.01%
|
0.228%
|
0.166%
|
-27.3%
|
|
3
|
Minnesota.
|
75
|
69
|
46124
|
21.31%
|
20.33%
|
0.171%
|
0.150%
|
-12.6%
|
|
4
|
South Dakota
|
4
|
12
|
8025
|
27.45%
|
26.38%
|
0.050%
|
0.150%
|
200.6%
|
|
5
|
Wisconsin
|
98
|
88
|
59901
|
18.77%
|
17.16%
|
0.172%
|
0.147%
|
-14.4%
|
|
6
|
Maine
|
23
|
33
|
23336
|
10.59%
|
9.84%
|
0.105%
|
0.141%
|
34.5%
|
|
7
|
North Carolina
|
98
|
147
|
111369
|
7.53%
|
7.04%
|
0.091%
|
0.132%
|
44.3%
|
|
8
|
California
|
371
|
520
|
576717
|
7.89%
|
7.32%
|
0.068%
|
0.090%
|
32.5%
|
|
9
|
Idaho
|
5
|
12
|
14121
|
13.23%
|
12.03%
|
0.038%
|
0.085%
|
121.9%
|
|
10
|
Oregon
|
22
|
32
|
38449
|
11.10%
|
10.27%
|
0.061%
|
0.083%
|
36.6%
|
|
11
|
Iowa
|
37
|
25
|
30180
|
23.48%
|
22.13%
|
0.126%
|
0.083%
|
-34.2%
|
|
12
|
Nebraska
|
11
|
12
|
15277
|
20.53%
|
19.76%
|
0.075%
|
0.079%
|
5.2%
|
|
13
|
Kansas
|
16
|
19
|
25779
|
16.68%
|
15.35%
|
0.064%
|
0.074%
|
14.7%
|
|
14
|
Massachusetts
|
43
|
74
|
106945
|
10.09%
|
9.07%
|
0.041%
|
0.069%
|
70.6%
|
|
15
|
Hawaii
|
8
|
8
|
12013
|
6.50%
|
6.29%
|
0.070%
|
0.067%
|
-5.1%
|
|
16
|
New Hampshire
|
11
|
6
|
9532
|
14.77%
|
13.27%
|
0.125%
|
0.063%
|
-49.6%
|
|
17
|
Washington
|
41
|
43
|
72659
|
8.70%
|
7.88%
|
0.059%
|
0.059%
|
0.7%
|
|
18
|
Wyoming
|
3
|
2
|
4140
|
20.12%
|
18.91%
|
0.072%
|
0.048%
|
-32.7%
|
|
19
|
Nevada
|
8
|
8
|
17432
|
8.77%
|
7.76%
|
0.052%
|
0.046%
|
-11.3%
|
|
20
|
Alaska
|
5
|
3
|
6737
|
10.14%
|
9.07%
|
0.082%
|
0.045%
|
-45.6%
|
|
21
|
Rhode Island
|
2
|
8
|
18464
|
9.81%
|
9.20%
|
0.011%
|
0.043%
|
288.7%
|
|
22
|
Michigan
|
57
|
63
|
148695
|
10.87%
|
9.75%
|
0.040%
|
0.042%
|
6.9%
|
|
23
|
Kentucky
|
32
|
46
|
119688
|
4.26%
|
3.93%
|
0.027%
|
0.038%
|
40.4%
|
|
24
|
New York
|
143
|
128
|
342099
|
8.99%
|
8.88%
|
0.042%
|
0.037%
|
-10.7%
|
|
25
|
North Dakota
|
2
|
2
|
5437
|
26.21%
|
24.63%
|
0.037%
|
0.037%
|
-1.4%
|
|
26
|
Florida
|
78
|
65
|
198748
|
6.20%
|
5.71%
|
0.042%
|
0.033%
|
-21.3%
|
|
27
|
Arizona
|
15
|
17
|
54096
|
6.90%
|
6.30%
|
0.030%
|
0.031%
|
5.0%
|
|
28
|
Maryland
|
17
|
16
|
53464
|
11.24%
|
10.73%
|
0.033%
|
0.030%
|
-8.2%
|
|
29
|
Arkansas
|
13
|
15
|
51070
|
7.18%
|
6.81%
|
0.027%
|
0.029%
|
10.2%
|
|
30
|
Colorado
|
10
|
10
|
34643
|
12.87%
|
11.61%
|
0.029%
|
0.029%
|
-0.4%
|
|
31
|
Utah
|
5
|
4
|
14327
|
16.08%
|
15.08%
|
0.036%
|
0.028%
|
-22.4%
|
|
< |
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