---
type: claim
domain: health
description: "Over half of PACE enrollees concentrated in California, New York, and Pennsylvania creates geographic selection bias that undermines claims of national applicability"
confidence: likely
source: "NORC at the University of Chicago, PACE Market Assessment Final Report, March 2025"
created: 2025-03-17
---

# PACE market concentration in three states limits national model validation and policy generalization

Over half of all PACE enrollees are concentrated in three states—California, New York, and Pennsylvania—out of 33 states plus DC with active programs. Only 13 states have 1,000+ enrollees. This geographic concentration means PACE's 50-year track record reflects the regulatory, demographic, and healthcare infrastructure characteristics of three specific states rather than a nationally validated model.

The concentration creates selection bias: California, New York, and Pennsylvania have specific combinations of Medicaid generosity, regulatory environments, and population density that may not generalize to other states. PACE's viability in these three states does not prove the model works nationally, and the failure to achieve meaningful penetration in 30+ other states suggests state-specific factors are critical to PACE success.

This matters for policy: advocates cite PACE as proof that full-risk capitated care works, but the evidence base is geographically narrow. Scaling PACE nationally requires either replicating the conditions that enabled success in CA/NY/PA or adapting the model to different state contexts—neither of which has been demonstrated at scale.

## Evidence

- NORC (2025): Over half of 90,580 PACE enrollees concentrated in 3 states (California, New York, Pennsylvania)
- Only 13 of 33 states + DC have 1,000+ enrollees
- 198 programs across 33 states, but most are small single-state operators
- Nearly half of all enrollees served by 10 largest parent organizations
- Most parent organizations operate single program in one state

## State-Specific Factors Enabling CA/NY/PA Success

Potential explanations for 3-state concentration:

1. **Medicaid generosity**: CA/NY have among the most generous Medicaid programs, improving PACE economics by ensuring higher capitated rates
2. **Regulatory support**: Early-adopter states with established PACE approval pathways and state-level advocacy
3. **Population density**: Urban concentration in these states supports PACE center economics (lower per-member overhead)
4. **Cultural factors**: Immigrant populations (especially Asian communities in CA) with strong preference for community-based elder care over institutionalization
5. **Healthcare infrastructure**: Existing integrated delivery systems (e.g., Kaiser in CA) provide operational templates

## Generalization Problem

The fact that PACE has NOT achieved similar penetration in other large states (Texas, Florida, Illinois) despite 50 years of operation suggests these state-specific factors are not easily replicable. Texas and Florida have large elderly populations but minimal PACE penetration, indicating that population size alone does not drive adoption. This implies that Medicaid generosity and regulatory environment are binding constraints, not just awareness or capital.

---

Relevant Notes:
- [[pace-serves-90k-enrollees-after-50-years-demonstrating-structural-barriers-prevent-full-capitation-scaling]]
- [[value-based-care-transitions-stall-at-the-payment-boundary-because-60-percent-of-payments-touch-value-metrics-but-only-14-percent-bear-full-risk]]

Topics:
- [[domains/health/_map]]
