The Role of Accelerated Approval Drug Spending on Medicaid Spending to Treat Rare Diseases

The Role of Accelerated Approval Drug Spending on Medicaid Spending to Treat Rare Diseases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Role of Accelerated Approval Drug Spending on Medicaid Spending to Treat Rare Diseases Kenneth Earl Thorpe, Jamie Sullivan, Baillie McGowan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4612847/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The accelerated approval pathway allows drugs for serious conditions that fill an unmet medical need to be approved based on a surrogate or intermediate clinical endpoint that is reasonably likely to predict a clinical benefit. The accelerated approval process has come under criticism from some state Medicaid programs who have sought to exclude paying for medications approved through this process. To examine the role that non-oncology rare disease drug spending assumes in state Medicaid programs, we examined state spending and changes in spending on the medications overall and as a percent of total state Medicaid spending in 2017 and 2022. Results On average nationally, pre-rebate spending on accelerated approval drugs to treat non-oncology rare diseases accounted for only 0.67 percent of state Medicaid spending in 2017 and 0.84 percent in 2022. In 2017 this ranged from a low of 0.008 percent in Delaware to a high of 1.7 percent in Indiana. The results were nearly identical in 2022. These medicines are neither a primary driver of state Medicaid spending or spending growth, nor an effective target for reform. Discussion Efforts to reduce the level and growth in Medicaid spending need to target the key drivers—dual eligible and the disabled populations that account for a third of Medicaid spending. 1 This would include providing more social services to address the determinants of health, integration of care coordination between Medicare and Medicaid and more efficient integration of the funding flows. Quite clearly, accelerated approval medications for non-oncology drugs to treat rare diseases are not contributing to the level and growth in Medicaid spending. Non-oncology rare disease medications role in the level and growth in Medicaid spending Background Created in 1992 to facilitate expedited access to potentially life-saving products for patients whose diseases warranted a novel approach to regulatory review, the accelerated approval pathway expedites the Food and Drug Administration’s (FDA’s) rigorous review of safety and efficacy to facilitate access for patients whose lives depend on timely access to therapies. In the 30 years since the pathway’s inception, the FDA has approved more than 250 drugs or biologics via the accelerated approval pathway, providing new, innovative treatment options, and hope for patients and their families. Millions of patients have benefitted significantly from therapies approved through accelerated approval (AA)–initially people diagnosed with HIV/AIDS, then people with various cancers, and today people with several rare diseases, many of whom are children. These medicines are reviewed and approved using the FDA’s same rigorous scientific review standards as with traditional approval. These standards, however, are applied to different, earlier clinical endpoints to expedite access for seriously ill patients. Despite that, both private and public payers, including several state Medicaid programs, have taken steps to avoid or severely restrict coverage of accelerated approval medicines, directly undermining the purpose of the pathway and federal patient protections required of Medicaid. The accelerated approval pathway allows drugs for serious conditions that fill an unmet medical need to be approved based on a surrogate or intermediate clinical endpoint that is reasonably likely to predict a clinical benefit. Studies demonstrating a drug’s effect on a surrogate or intermediate clinical endpoint must meet standards demonstrating the study is “adequate and well controlled.” The FDA created the accelerated approval pathway 30 years ago in response to the HIV/AIDS epidemic where the surrogate endpoint of immune cell response was used to predict survival. By not waiting years to confirm survival as an outcome, people with HIV/AIDS gained earlier access to FDA-approved therapies. Using a surrogate endpoint reasonably likely to predict long-term clinical benefits, which could otherwise take years to measure, saves valuable time for patients whose critical illness does not afford time to wait. Congress first codified the accelerated approval pathway in 1992 and then modernized and enhanced it in 2012 to expand the pathway’s use beyond treatments for HIV/AIDS or oncology to include rare diseases. The accelerated approval process has come under criticism from some state Medicaid programs who have sought to exclude paying for medications approved through this process. For example, Oregon had submitted a waiver to the Centers for Medicare and Medicaid Services (CMS) to do so but that component of the application was ultimately denied following community input. Efforts to restrict access to therapies approved using the accelerated approval pathway do not target the significant drivers of the rare disease economic impact. The 2022 National Economic Burden of Rare Disease Study in the U.S found the overall economic impact of rare diseases in 2019 exceeded $ 966 billion. Of the costs assessed, non-medical and indirect costs accounted for nearly 60 percent of overall costs underscoring that significant costs are shouldered by families. Of the $ 449 billion assessed in direct medical costs, hospital inpatient care was the largest cost category representing 32% of the direct costs, prescription medications represented 18% of direct medical costs, however this 18% reflects all treatments associated with rare diseases (approved both through accelerated approval and the traditional FDA process), of which only a fragment have been approved using accelerated approval. This breakdown reflects the reality that 95% of rare diseases still lack an FDA-approved treatment. . To address the “high costs” of accelerated approval drugs, a technical advisory committee to Congress on Medicaid has proposed requiring higher rebates on the drugs until confirmatory studies were completed. Other efforts and proposals have emerged that would further differentiate reimbursement and access to drugs approved via the accelerated approval pathway, including a proposed demonstration project from the Centers for Medicare and Medicaid Innovation. These policy proposals would apply to all therapies using the accelerated approval pathway, despite there being distinct subsets of drugs including HIV/AIDS, oncology and non-oncology rare diseases. Among the drugs targeted for exclusion from state Medicaid programs or higher rebates include rare and orphan disease drugs. These drugs are generally defined as treatments for medical conditions that affect fewer than 200.000 patients in the US. Data and Methods To examine the role that non-oncology rare disease drug spending assumes in state Medicaid programs, we examined state spending and changes in spending on the medications overall and as a percent of total state Medicaid spending in 2017 and 2022. We use public data on state Medicaid spending flowing through the accelerated approval process. From these data we identified a list of accelerated approvals that were identified as non-oncology, non-infectious disease rare disease drug approvals. The data reported for drug spending are before any rebates. Because most accelerated approval drugs convert to traditional approval, the analysis considers conversion status and categorizes the spending contribution from an accelerated approval drug to prescription drugs generally (non-accelerated drugs in our tables) once a drug completed confirmatory trials and FDA changed its approval status to traditional approval. Total state Medicaid spending includes drug spending that is post-rebate. As a result, the results reported are an upper estimate of the role this subset of rare drug spending assumes as a share of total state Medicaid spending. Spending includes Medicaid managed care and fee-for-service spending. Accelerated approval drugs were identified from the FDA Center for Drug Evaluation and Research drug and biologic accelerated approvals document as of 2022. As of the end of 2022, no orphan designated biological product had yet been approved via the accelerated approval pathway. The list of the rare disease medications included in the analysis to treat non-oncology, non-infectious disease rare diseases is listed in Appendix 1. These data informed calculations of the Medicaid amount reimbursed for each year. Total Medicaid drug reimbursements for the year were also tabulated. Total state Medicaid spending was collected from state financial management reports for 2017 and 2022. Results We present three sets of tables. Table 1 tabulates by state (and the District of Columbia (DC)) total accelerated approval drug spending on medications for rare diseases, total non-accelerated approval drugs and accelerated approval spending as a percent of total state Medicaid drug spending. Table 1 reports these in nominal dollars. Table 2 presents the same tabulation except the dollars are adjusted for inflation and reported as spending in 2022 dollars (using the consumer price index-urban). Finally, Table 3 presents the nominal spending on accelerated approval rare disease drugs as a percent of total state Medicaid spending. As reported in Table 1 the range of spending on the analyzed accelerated approval rare disease treatment drugs as a percent of total drug spending was 0.7 percent in the District of Columbia to a high of 4.1 percent of total drug spending in Alabama in 2017. The average across the 51 states and the District of Columbia was 2.2 percent of total drug spending in 2017. The results are nearly identical in 2022 though lower at 1.9 percent of total drug spending. Accelerated approval rare disease drugs ranged from a low of 0.35 percent of drug spending in Rhode Island and Vermont and even lower in the District of Columbia (0.32 percent) to a high of 5.1 percent in Kansas in 2022. Adjusting for inflation in Table 2 , total spending on accelerated approval drugs to treat rare disease increased slightly between 2017 and 2022, from $ 1.77 billion to $ 1.86 billion, a 5.2 percent increase. However, inflation adjusted spending on non-accelerated approval drugs increased sharply from $ 69.5 billion to $ 83.8 billion in 2022, a 20.7 percent increase, 4 times higher than the accelerated approval drugs. Table 3 presents tabulations of the share of analyzed accelerated approval drug spending of total state Medicaid spending. On average nationally, pre-rebate spending on accelerated approval drugs to treat non-oncology rare diseases accounted for only 0.67 percent of state Medicaid spending in 2017 and 0.84 percent in 2022. In 2017 this ranged from a low of 0.008 percent in Delaware to a high of 1.7 percent in Indiana. The results were nearly identical in 2022. Accelerated approval drug spending to treat non-oncology, non-infectious disease rare diseases as a share of total state Medicaid spending ranged from a low of 0.09 percent in the District of Columbia to a high of 2.05 percent in Indiana in 2022. Across all jurisdictions, the average percent of the state Medicaid budget was similar in 2022 as 2017, 0.84 percent. Accounting for rebates would reduce those contributions to state Medicaid spending even further. Discussion and Conclusions These medicines are neither a primary driver of state Medicaid spending or spending growth, nor an effective target for reform. Efforts to reduce the level and growth in Medicaid spending need to target the key drivers—dual eligible and the disabled populations that account for a third of Medicaid spending. 1 This would include providing more social services to address the determinants of health, integration of care coordination between Medicare and Medicaid and more efficient integration of the funding flows. Quite clearly, accelerated approval medications for non-oncology drugs to treat rare diseases are not contributing to the level and growth in Medicaid spending. Table 1. Rare Drug State Medicaid Spending as Percent of Total Drug Spending, Nominall Dollars, 2017-2022 2017 2022 State Medicaid Non-Accelerated Rx Medicaid Accelerated Rx % of State Medicaid Medicaid Non-Accelerated Rx Medicaid Accelerated Rx % of State Medicaid AK 133,047,085 2,071,263 1.53% 203,482,175 3,120,549 1.51% AL 669,811,723 28,672,277 4.10% 974,574,474 21,235,212 2.13% AR 376,024,134 7,474,452 1.95% 494,761,814 7,503,590 1.49% AZ 1,199,589,546 26,663,237 2.17% 1,726,813,636 50,151,045 2.82% CA 7,851,172,807 202,694,746 2.52% 11,050,383,098 288,718,646 2.55% CO 895,415,128 14,625,793 1.61% 1,389,020,919 15,621,678 1.11% CT 1,196,547,790 15,038,496 1.24% 1,721,193,087 16,732,858 0.96% DC 267,611,312 1,854,833 0.69% 240,076,443 770,392 0.32% DE 26,340,185 68,710 0.26% 266,416,852 5,368,026 1.98% FL 2,807,672,222 106,647,670 3.66% 3,593,360,159 126,208,612 3.39% GA 1,108,304,832 44,032,049 3.82% 1,342,163,340 37,201,625 2.70% HI 200,136,478 3,549,394 1.74% 215,265,723 3,481,418 1.59% IA 352,810,698 11,340,548 3.11% 741,374,072 14,635,626 1.94% ID 187,817,844 3,297,585 1.73% 532,505,781 10,332,580 1.90% IL 1,916,623,108 56,194,616 2.85% 2,888,829,014 71,208,000 2.41% IN 1,467,177,308 55,933,307 3.67% 2,380,027,693 81,934,472 3.33% KS 354,920,288 9,814,519 2.69% 265,320,232 14,287,414 5.11% KY 1,226,985,481 14,363,129 1.16% 1,993,529,599 22,454,729 1.11% LA 1,029,566,746 22,834,910 2.17% 2,396,713,286 35,724,781 1.47% MA 1,410,629,442 22,185,253 1.55% 2,127,942,062 28,777,999 1.33% MD 1,107,957,349 17,510,285 1.56% 1,606,950,641 26,324,313 1.61% ME 217,306,989 2,756,973 1.25% 452,294,704 6,257,270 1.36% MI 2,150,832,930 50,171,219 2.28% 3,223,190,796 58,042,022 1.77% MN 951,342,053 28,544,858 2.91% 1,319,090,214 36,312,740 2.68% MO 1,200,549,758 25,974,522 2.12% 1,484,972,316 38,580,583 2.53% MS 427,032,050 15,119,517 3.42% 408,158,185 8,318,943 2.00% MT 201,531,881 5,701,541 2.75% 394,794,601 7,342,098 1.83% NC 1,740,250,668 40,548,107 2.28% 2,330,222,475 49,740,291 2.09% ND 51,330,931 811,167 1.56% 97,583,203 509,095 0.52% NE 175,205,042 2,409,900 1.36% 407,910,324 9,181,513 2.20% NH 99,189,168 1,155,423 1.15% 252,367,553 6,534,634 2.52% NJ 1,404,537,336 37,036,092 2.57% 1,631,943,418 42,017,599 2.51% NM 429,330,157 5,500,046 1.26% 506,186,137 8,597,409 1.67% NV 473,843,553 13,139,151 2.70% 559,395,326 14,216,542 2.48% NY 5,829,268,514 144,150,306 2.41% 6,764,122,830 150,821,061 2.18% OH 3,402,230,358 86,828,604 2.49% 4,176,140,791 103,453,544 2.42% OK 482,998,932 17,148,816 3.43% 856,691,371 15,744,203 1.80% OR 692,460,900 15,425,390 2.18% 788,742,202 14,385,851 1.79% PA 3,160,940,780 75,388,299 2.33% 3,508,116,320 72,142,517 2.02% RI 216,309,688 3,031,424 1.38% 339,266,810 1,175,048 0.35% SC 526,662,256 21,495,162 3.92% 703,446,267 20,427,021 2.82% SD 98,848,284 3,403,779 3.33% 156,941,497 6,293,466 3.86% TN 1,020,077,285 25,741,369 2.46% 1,437,957,588 37,512,074 2.54% TX 3,288,329,001 104,535,086 3.08% 3,793,302,258 147,947,276 3.75% UT 190,228,381 2,136,774 1.11% 477,031,534 9,263,434 1.90% VA 920,439,229 24,277,717 2.57% 5,077,628,513 68,847,989 1.34% VT 159,336,717 2,205,689 1.37% 194,264,134 673,315 0.35% WA 1,133,992,690 27,652,117 2.38% 1,510,240,192 20,737,221 1.35% WI 1,143,138,974 22,556,271 1.94% 1,929,066,883 15,537,415 0.80% WV 583,436,427 9,040,465 1.53% 849,891,110 9,347,537 1.09% WY 35,128,447 848,914 2.36% 45,588,404 792,842 1.71% 58,192,270,885 1,481,601,770 2.2% 75,788,508,629 1,624,480,152 1.90% * State reported drug utilization for covered outpatient drugs paid for by state Medicaid agencies data downloaded from https://www.medicaid.gov/medicaid/prescription-drugs/state-drug-utilization-data/index.html **Accelerated Approval and conversion dates from AA Orphan approval list 1.11.23.xlsx Inflation adjusted using GDP price deflator Table 2. Accelerated Approval Drugs to Treat Rare Diseases as Percent Total State Drug Spending, 2017-2022 (inflation adjusted) 2017 2022 Medicaid Non-Accelerated Rx Medicaid Accelerated Rx % of State Medicaid Medicaid Non-Accelerated Rx Medicaid Accelerated Rx % of State Medicaid AK 158,848,296 2,472,933 1.53% 203,482,175 3,120,549 1.51% AL 799,705,246 34,232,561 4.10% 974,574,474 21,235,212 2.13% AR 448,944,774 8,923,938 1.95% 494,761,814 7,503,590 1.49% AZ 1,432,220,456 31,833,917 2.17% 1,726,813,636 50,151,045 2.82% CA 9,373,714,818 242,002,410 2.52% 11,050,383,098 288,718,646 2.55% CO 1,069,058,885 17,462,106 1.61% 1,389,020,919 15,621,678 1.11% CT 1,428,588,828 17,954,842 1.24% 1,721,193,087 16,732,858 0.96% DC 319,507,950 2,214,532 0.69% 240,076,443 770,392 0.32% DE 31,448,217 82,035 0.26% 266,416,852 5,368,026 1.98% FL 3,352,151,245 127,329,365 3.66% 3,593,360,159 126,208,612 3.39% GA 1,323,233,317 52,570,982 3.82% 1,342,163,340 37,201,625 2.70% HI 238,948,030 4,237,711 1.74% 215,265,723 3,481,418 1.59% IA 421,229,662 13,539,768 3.11% 741,374,072 14,635,626 1.94% ID 224,240,500 3,937,071 1.73% 532,505,781 10,332,580 1.90% IL 2,288,305,053 67,092,181 2.85% 2,888,829,014 71,208,000 2.41% IN 1,751,700,288 66,780,198 3.67% 2,380,027,693 81,934,472 3.33% KS 423,748,356 11,717,803 2.69% 265,320,232 14,287,414 5.11% KY 1,464,929,162 17,148,505 1.16% 1,993,529,599 22,454,729 1.11% LA 1,229,225,918 27,263,180 2.17% 2,396,713,286 35,724,781 1.47% MA 1,684,186,355 26,487,538 1.55% 2,127,942,062 28,777,999 1.33% MD 1,322,818,449 20,905,975 1.56% 1,606,950,641 26,324,313 1.61% ME 259,448,339 3,291,620 1.25% 452,294,704 6,257,270 1.36% MI 2,567,934,121 59,900,694 2.28% 3,223,190,796 58,042,022 1.77% MN 1,135,831,465 34,080,432 2.91% 1,319,090,214 36,312,740 2.68% MO 1,433,366,878 31,011,642 2.12% 1,484,972,316 38,580,583 2.53% MS 509,844,422 18,051,575 3.42% 408,158,185 8,318,943 2.00% MT 240,614,036 6,807,215 2.75% 394,794,601 7,342,098 1.83% NC 2,077,729,519 48,411,416 2.28% 2,330,222,475 49,740,291 2.09% ND 61,285,303 968,473 1.56% 97,583,203 509,095 0.52% NE 209,181,754 2,877,241 1.36% 407,910,324 9,181,513 2.20% NH 118,424,469 1,379,489 1.15% 252,367,553 6,534,634 2.52% NJ 1,676,912,833 44,218,332 2.57% 1,631,943,418 42,017,599 2.51% NM 512,588,191 6,566,644 1.26% 506,186,137 8,597,409 1.67% NV 565,733,865 15,687,166 2.70% 559,395,326 14,216,542 2.48% NY 6,959,711,885 172,104,715 2.41% 6,764,122,830 150,821,061 2.18% OH 4,062,009,326 103,666,878 2.49% 4,176,140,791 103,453,544 2.42% OK 576,664,705 20,474,408 3.43% 856,691,371 15,744,203 1.80% OR 826,746,676 18,416,765 2.18% 788,742,202 14,385,851 1.79% PA 3,773,927,564 90,008,007 2.33% 3,508,116,320 72,142,517 2.02% RI 258,257,635 3,619,294 1.38% 339,266,810 1,175,048 0.35% SC 628,795,457 25,663,621 3.92% 703,446,267 20,427,021 2.82% SD 118,017,480 4,063,858 3.33% 156,941,497 6,293,466 3.86% TN 1,217,896,205 30,733,275 2.46% 1,437,957,588 37,512,074 2.54% TX 3,926,019,598 124,807,098 3.08% 3,793,302,258 147,947,276 3.75% UT 227,118,500 2,551,149 1.11% 477,031,534 9,263,434 1.90% VA 1,098,935,797 28,985,784 2.57% 5,077,628,513 68,847,989 1.34% VT 190,236,158 2,633,428 1.37% 194,264,134 673,315 0.35% WA 1,353,902,704 33,014,565 2.38% 1,510,240,192 20,737,221 1.35% WI 1,364,822,684 26,930,505 1.94% 1,929,066,883 15,537,415 0.80% WV 696,579,583 10,793,641 1.53% 849,891,110 9,347,537 1.09% WY 41,940,746 1,013,540 2.36% 45,588,404 792,842 1.71% Total $69,477,231,703 $1,768,922,021 $83,827,252,056 $1,862,546,188 Table 3. Accelerated Approval Drug Spending to Treat Rare Disease as Percent total State Medicaid Spending, 2017-2022 Note: In calculating percentage of spending, Total Medicaid Spending (denominator) includes drug rebates, but the spending on rare disease AA drugs (numerator) does not include rebates as the information is not available. 2017 2022 Rare Drug Accelerated Approval Spending as Percent State Medicaid Spending AK 0.321 0.532 AL 1.655 1.346 AR 0.483 0.451 AZ 0.909 1.453 CA 0.562 0.715 CO 0.424 0.379 CT 0.464 0.476 DC 0.236 0.091 DE 0.008 0.583 FL 1.148 1.180 GA 1.295 0.960 HI 0.424 0.388 IA 0.724 0.831 ID 0.593 1.492 IL 0.919 0.781 IN 1.71 2.048 KS 0.667 1.000 KY 0.654 0.891 LA 0.689 1.187 MA 0.272 0.363 MD 0.385 0.536 ME 0.288 0.651 MI 0.614 1.127 MN 0.554 0.630 MO 0.675 1.341 MS 1.043 0.877 MT 1.485 1.648 NC 0.881 1.032 ND 0.161 0.106 NE 0.236 0.916 NH 0.133 0.719 NJ 0.394 0.597 NM 0.473 0.672 NV 1.396 1.225 NY 0.36 0.516 OH 1.156 1.425 OK 0.924 1.250 OR 0.667 0.454 PA 0.665 0.536 RI 0.27 0.110 SC 1.193 1.135 SD 0.917 1.626 TN 0.765 1.177 TX 0.65 0.818 UT 0.274 0.955 VA 0.523 1.200 VT 0.314 0.106 WA 0.6 0.377 WI 0.65 0.428 WV 1.027 1.098 WY 0.278 0.282 Average 0.67% 0.84% Declarations Ethics Approval N/A Consent N/A Data Availability: Upon request from Dr. Thorpe Funding: To Dr.Thorpe from EveryLife Foundation for Rare Diseases Contributions; The design and analysis was conducted by Dr Thorpe the co-authors contributed to the interpretation and implications and discussion. Acknowledgments: The authors thanks Annie Kennedy and Peter Joski for their contributions to the paper. References https://www.macpac.gov/wp-content/uploads/2022/12/MACSTATS_Dec2022_WEB-508.pdf at Exhibit 18. Accessed on March 3, 2023 at https://www.fda.gov/media/151146/download FDA Guidance for Industry: Expedited Programs for Serious Conditions—Drugs and Biologics. May 2014. Available from: https://www.fda.gov/files/drugs/published/Expedited-Programs-for-Serious-ConditionsDrugs-and-Biologics.pdf. FDA. Accelerated Approval. Jan. 4, 2018. Available from: https://www.fda.gov/patients/fast-trackbreakthrough-therapy-accelerated-approval-priority-review/accelerated-approval. Food and Drug Administration Regulatory Modernization Act of 1997. Food and Drug Administration Safety and Innovation Act of 2012 (FDASIA) The Grace Yang, Inna Cintina, Anne Pariser, Elisabeth Oehrlein, Jamie Sullivan, Annie Kennedy. The national economic burden of rare disease in the United States in 2019 , Orphanet Journal of Rare Diseases, April 2022 Accessed on March 1 at https://www.macpac.gov/publication/high-cost-specialty-drugs-moving-towards-recommendations/ Sachs R, Donohue J, Dusetzina S. Reforming Reimbursement for the US Food and Drug Administration’s Accelerated Approval Program to Support State Medicaid Programs. JAMA Health Forum. 2022: 3(11):e224115. doi 10.001/jamahealthforum.2022.4115 * state reported drug utilization for covered outpatient drugs paid for by state Medicaid agencies data downloaded from https://www.medicaid.gov/medicaid/prescription-drugs/state-drug-utilization-data/index.html data downloaded from https://www.medicaid.gov/medicaid/prescription-drugs/state-drug-utilization-data/index.html These data are available from: https://www.macpac.gov/wp-content/uploads/2022/12/MACSTATS_Dec2022_WEB-508.pdf and https://www.macpac.gov/wp-content/uploads/2018/12/December-2018-MACStats-Data-Book.pdf https://www.macpac.gov/wp-content/uploads/2022/12/MACSTATS_Dec2022_WEB-508.pdf at Exhibit 18. Supplementary Files Appendix1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4612847","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":423766228,"identity":"1a52e1b5-8f7d-41ca-8554-24690b53f460","order_by":0,"name":"Kenneth Earl Thorpe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYBACCQYeMC0HE2BsIKiFDaLFmHQtiTCVhLVIzu89+Lhyh016v9jhY595GGxkNxwgoEWajS/Z8OyZtNyZs9OSZ/MwpBkT1CLHxmMm2dh2OHfD7RxjZh6Gw4nEavmfbg/R8p+wFmmIlgMJBtJgLQcIa5FsyzE2bDyTbDjjdloy4xyDZOOZhLRIHD5j+LBxh508/+zkwwxvKuxk+whpAQNYXDDxGBCjHFkL4w9idYyCUTAKRsGIAgADgj2eKZa7oAAAAABJRU5ErkJggg==","orcid":"","institution":"Emory University Rollins School of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Kenneth","middleName":"Earl","lastName":"Thorpe","suffix":""},{"id":423766229,"identity":"93d6f51b-8013-4436-8c78-b99ffc7dc374","order_by":1,"name":"Jamie Sullivan","email":"","orcid":"","institution":"EveryLife Foundation for Rare Diseases","correspondingAuthor":false,"prefix":"","firstName":"Jamie","middleName":"","lastName":"Sullivan","suffix":""},{"id":423766230,"identity":"eeb23dc4-25df-43c1-afa5-8c109b6a79f3","order_by":2,"name":"Baillie McGowan","email":"","orcid":"","institution":"EveryLife Foundation for Rare Diseases","correspondingAuthor":false,"prefix":"","firstName":"Baillie","middleName":"","lastName":"McGowan","suffix":""}],"badges":[],"createdAt":"2024-06-20 15:37:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4612847/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4612847/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82828295,"identity":"f36381e0-41cb-4124-a237-78d6b9ddf18d","added_by":"auto","created_at":"2025-05-15 16:35:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1289746,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4612847/v1/56fb98e8-7829-47f8-9466-b5be837d69b7.pdf"},{"id":78663116,"identity":"ae9a735c-8498-4e08-b693-31fa97d25e6c","added_by":"auto","created_at":"2025-03-17 10:38:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":148071,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4612847/v1/a973339848fc541964b0f271.docx"}],"financialInterests":"","formattedTitle":"The Role of Accelerated Approval Drug Spending on Medicaid Spending to Treat Rare Diseases","fulltext":[{"header":"Background","content":"\u003cp\u003eCreated in 1992 to facilitate expedited access to potentially life-saving products for patients whose diseases warranted a novel approach to regulatory review, the accelerated approval pathway expedites the Food and Drug Administration\u0026rsquo;s (FDA\u0026rsquo;s) rigorous review of safety and efficacy to facilitate access for patients whose lives depend on timely access to therapies. In the 30 years since the pathway\u0026rsquo;s inception, the FDA has approved more than 250 drugs or biologics via the accelerated approval pathway, providing new, innovative treatment options, and hope for patients and their families.\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e Millions of patients have benefitted significantly from therapies approved through accelerated approval (AA)\u0026ndash;initially people diagnosed with HIV/AIDS, then people with various cancers, and today people with several rare diseases, many of whom are children. These medicines are reviewed and approved using the FDA\u0026rsquo;s same rigorous scientific review standards as with traditional approval. These standards, however, are applied to different, earlier clinical endpoints to expedite access for seriously ill patients. Despite that, both private and public payers, including several state Medicaid programs, have taken steps to avoid or severely restrict coverage of accelerated approval medicines, directly undermining\u003ca class=\"FNLink\" href=\"#Fn3\" id=\"#FNLinkFn3\"\u003e\u003c/a\u003e the purpose of the pathway and federal patient protections required of Medicaid.\u003c/p\u003e \u003cp\u003eThe accelerated approval pathway allows drugs for serious conditions that fill an unmet medical need to be approved based on a surrogate or intermediate clinical endpoint that is reasonably likely to predict a clinical benefit.\u003ca class=\"FNLink\" href=\"#Fn4\" id=\"#FNLinkFn4\"\u003e\u003c/a\u003e Studies demonstrating a drug\u0026rsquo;s effect on a surrogate or intermediate clinical endpoint must meet standards demonstrating the study is \u0026ldquo;adequate and well controlled.\u0026rdquo; The FDA created the accelerated approval pathway 30 years ago in response to the HIV/AIDS epidemic where the surrogate endpoint of immune cell response was used to predict survival. By not waiting years to confirm survival as an outcome, people with HIV/AIDS gained earlier access to FDA-approved therapies. Using a surrogate endpoint reasonably likely to predict long-term clinical benefits, which could otherwise take years to measure, saves valuable time for patients whose critical illness does not afford time to wait. Congress first codified the accelerated approval pathway in 1992\u003ca class=\"FNLink\" href=\"#Fn5\" id=\"#FNLinkFn5\"\u003e\u003c/a\u003e and then modernized and enhanced it in 2012 to expand the pathway\u0026rsquo;s use beyond treatments for HIV/AIDS or oncology to include rare diseases.\u003ca class=\"FNLink\" href=\"#Fn6\" id=\"#FNLinkFn6\"\u003e\u003c/a\u003e\u003c/p\u003e \u003cp\u003e The accelerated approval process has come under criticism from some state Medicaid programs who have sought to exclude paying for medications approved through this process. For example, Oregon had submitted a waiver to the Centers for Medicare and Medicaid Services (CMS) to do so but that component of the application was ultimately denied following community input. Efforts to restrict access to therapies approved using the accelerated approval pathway do not target the significant drivers of the rare disease economic impact. The 2022 National Economic Burden of Rare Disease Study in the U.S found the overall economic impact of rare diseases in 2019 exceeded \u003cspan\u003e$\u003c/span\u003e966\u0026nbsp;billion. Of the costs assessed, non-medical and indirect costs accounted for nearly 60 percent of overall costs underscoring that significant costs are shouldered by families. Of the \u003cspan\u003e$\u003c/span\u003e449\u0026nbsp;billion assessed in direct medical costs, hospital inpatient care was the largest cost category representing 32% of the direct costs, prescription medications represented 18% of direct medical costs, however this 18% reflects all treatments associated with rare diseases (approved both through accelerated approval and the traditional FDA process), of which only a fragment have been approved using accelerated approval. This breakdown reflects the reality that 95% of rare diseases still lack an FDA-approved treatment. \u003ca class=\"FNLink\" href=\"#Fn7\" id=\"#FNLinkFn7\"\u003e\u003c/a\u003e. To address the \u0026ldquo;high costs\u0026rdquo; of accelerated approval drugs, a technical advisory committee to Congress on Medicaid has proposed requiring higher rebates on the drugs until confirmatory studies were completed.\u003ca class=\"FNLink\" href=\"#Fn8\" id=\"#FNLinkFn8\"\u003e\u003c/a\u003eOther efforts and proposals have emerged that would further differentiate reimbursement and access to drugs approved via the accelerated approval pathway, including a proposed demonstration project from the Centers for Medicare and Medicaid Innovation. These policy proposals would apply to all therapies using the accelerated approval pathway, despite there being distinct subsets of drugs including HIV/AIDS, oncology and non-oncology rare diseases.\u003ca class=\"FNLink\" href=\"#Fn9\" id=\"#FNLinkFn9\"\u003e\u003c/a\u003e \u003c/p\u003e \u003cp\u003eAmong the drugs targeted for exclusion from state Medicaid programs or higher rebates include rare and orphan disease drugs. These drugs are generally defined as treatments for medical conditions that affect fewer than 200.000 patients in the US.\u003c/p\u003e"},{"header":"Data and Methods","content":"\u003cp\u003eTo examine the role that non-oncology rare disease drug spending assumes in state Medicaid programs, we examined state spending and changes in spending on the medications overall and as a percent of total state Medicaid spending in 2017 and 2022. We use public data on state Medicaid spending flowing through the accelerated approval process.\u003ca class=\"FNLink\" href=\"#Fn10\" id=\"#FNLinkFn10\"\u003e\u003c/a\u003e From these data we identified a list of accelerated approvals that were identified as non-oncology, non-infectious disease rare disease drug approvals. The data reported for drug spending are before any rebates. Because most accelerated approval drugs convert to traditional approval, the analysis considers conversion status and categorizes the spending contribution from an accelerated approval drug to prescription drugs generally (non-accelerated drugs in our tables) once a drug completed confirmatory trials and FDA changed its approval status to traditional approval. Total state Medicaid spending includes drug spending that is post-rebate. As a result, the results reported are an upper estimate of the role this subset of rare drug spending assumes as a share of total state Medicaid spending.\u003c/p\u003e \u003cp\u003eSpending includes Medicaid managed care and fee-for-service spending. Accelerated approval drugs were identified from the FDA Center for Drug Evaluation and Research drug and biologic accelerated approvals document as of 2022. As of the end of 2022, no orphan designated biological product had yet been approved via the accelerated approval pathway. The list of the rare disease medications included in the analysis to treat non-oncology, non-infectious disease rare diseases is listed in Appendix 1. These data informed calculations of the Medicaid amount reimbursed for each year. Total Medicaid drug reimbursements for the year were also tabulated.\u003ca class=\"FNLink\" href=\"#Fn11\" id=\"#FNLinkFn11\"\u003e\u003c/a\u003e Total state Medicaid spending was collected from state financial management reports for 2017 and 2022.\u003ca class=\"FNLink\" href=\"#Fn12\" id=\"#FNLinkFn12\"\u003e\u003c/a\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe present three sets of tables. Table\u0026nbsp;1 tabulates by state (and the District of Columbia (DC)) total accelerated approval drug spending on medications for rare diseases, total non-accelerated approval drugs and accelerated approval spending as a percent of total state Medicaid drug spending. Table\u0026nbsp;1 reports these in nominal dollars. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the same tabulation except the dollars are adjusted for inflation and reported as spending in 2022 dollars (using the consumer price index-urban). Finally, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the nominal spending on accelerated approval rare disease drugs as a percent of total state Medicaid spending.\u003c/p\u003e \u003cp\u003eAs reported in Table\u0026nbsp;1 the range of spending on the analyzed accelerated approval rare disease treatment drugs as a percent of total drug spending was 0.7 percent in the District of Columbia to a high of 4.1 percent of total drug spending in Alabama in 2017. The average across the 51 states and the District of Columbia was 2.2 percent of total drug spending in 2017. The results are nearly identical in 2022 though lower at 1.9 percent of total drug spending. Accelerated approval rare disease drugs ranged from a low of 0.35 percent of drug spending in Rhode Island and Vermont and even lower in the District of Columbia (0.32 percent) to a high of 5.1 percent in Kansas in 2022.\u003c/p\u003e \u003cp\u003eAdjusting for inflation in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e, total spending on accelerated approval drugs to treat rare disease increased slightly between 2017 and 2022, from \u003cspan\u003e$\u003c/span\u003e1.77\u0026nbsp;billion to \u003cspan\u003e$\u003c/span\u003e1.86\u0026nbsp;billion, a 5.2 percent increase. However, inflation adjusted spending on non-accelerated approval drugs increased sharply from \u003cspan\u003e$\u003c/span\u003e69.5\u0026nbsp;billion to \u003cspan\u003e$\u003c/span\u003e83.8\u0026nbsp;billion in 2022, a 20.7 percent increase, 4 times higher than the accelerated approval drugs.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents tabulations of the share of analyzed accelerated approval drug spending of total state Medicaid spending. On average nationally, pre-rebate spending on accelerated approval drugs to treat non-oncology rare diseases accounted for only 0.67 percent of state Medicaid spending in 2017 and 0.84 percent in 2022. In 2017 this ranged from a low of 0.008 percent in Delaware to a high of 1.7 percent in Indiana. The results were nearly identical in 2022. Accelerated approval drug spending to treat non-oncology, non-infectious disease rare diseases as a share of total state Medicaid spending ranged from a low of 0.09 percent in the District of Columbia to a high of 2.05 percent in Indiana in 2022. Across all jurisdictions, the average percent of the state Medicaid budget was similar in 2022 as 2017, 0.84 percent. Accounting for rebates would reduce those contributions to state Medicaid spending even further.\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eThese medicines are neither a primary driver of state Medicaid spending or spending growth, nor an effective target for reform. Efforts to reduce the level and growth in Medicaid spending need to target the key drivers\u0026mdash;dual eligible and the disabled populations that account for a third of Medicaid spending.\u003ca href=\"#_edn1\" name=\"_ednref1\" title=\"\"\u003e\u003c/a\u003e\u003csup\u003e1\u003c/sup\u003e This would include providing more social services to address the determinants of health, integration of care coordination between Medicare and Medicaid and more efficient integration of the funding flows. Quite clearly, accelerated approval medications for non-oncology drugs to treat rare diseases are not contributing to the level and growth in Medicaid spending.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"724\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"bottom\" style=\"width: 37.2549%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Rare Drug State Medicaid Spending as Percent of Total Drug Spending, Nominall Dollars, 2017-2022\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eState\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedicaid Non-Accelerated Rx\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedicaid Accelerated Rx\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of State Medicaid\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedicaid Non-Accelerated Rx\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedicaid Accelerated Rx\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of State Medicaid\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eAK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e133,047,085\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e2,071,263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.53%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e203,482,175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e3,120,549\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.51%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e669,811,723\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e28,672,277\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e4.10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e974,574,474\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e21,235,212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.13%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eAR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e376,024,134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e7,474,452\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.95%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e494,761,814\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e7,503,590\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.49%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eAZ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,199,589,546\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e26,663,237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e1,726,813,636\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e50,151,045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.82%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e7,851,172,807\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e202,694,746\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.52%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e11,050,383,098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e288,718,646\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.55%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eCO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e895,415,128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e14,625,793\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.61%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e1,389,020,919\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e15,621,678\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,196,547,790\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e15,038,496\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.24%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e1,721,193,087\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e16,732,858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e0.96%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e267,611,312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e1,854,833\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e0.69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e240,076,443\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e770,392\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e0.32%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eDE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e26,340,185\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e68,710\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e0.26%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e266,416,852\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e5,368,026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.98%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eFL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e2,807,672,222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e106,647,670\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e3.66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e3,593,360,159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e126,208,612\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e3.39%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,108,304,832\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e44,032,049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e3.82%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e1,342,163,340\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e37,201,625\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.70%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eHI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e200,136,478\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e3,549,394\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e215,265,723\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e3,481,418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.59%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e352,810,698\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e11,340,548\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e3.11%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e741,374,072\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e14,635,626\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.94%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eID\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e187,817,844\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e3,297,585\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.73%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e532,505,781\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e10,332,580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,916,623,108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e56,194,616\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e2,888,829,014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e71,208,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.41%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eIN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,467,177,308\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e55,933,307\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e3.67%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e2,380,027,693\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e81,934,472\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e3.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eKS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e354,920,288\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e9,814,519\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e265,320,232\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e14,287,414\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e5.11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eKY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,226,985,481\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e14,363,129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.16%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e1,993,529,599\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e22,454,729\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eLA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,029,566,746\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e22,834,910\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e2,396,713,286\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e35,724,781\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.47%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,410,629,442\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e22,185,253\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.55%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e2,127,942,062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e28,777,999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,107,957,349\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e17,510,285\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.56%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e1,606,950,641\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e26,324,313\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.61%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eME\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e217,306,989\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e2,756,973\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e452,294,704\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e6,257,270\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.36%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e2,150,832,930\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e50,171,219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.28%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e3,223,190,796\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e58,042,022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.77%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eMN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e951,342,053\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e28,544,858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.91%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e1,319,090,214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e36,312,740\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.68%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eMO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,200,549,758\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e25,974,522\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.12%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e1,484,972,316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e38,580,583\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.53%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e427,032,050\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e15,119,517\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e3.42%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e408,158,185\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e8,318,943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eMT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e201,531,881\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e5,701,541\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e394,794,601\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e7,342,098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.83%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eNC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,740,250,668\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e40,548,107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.28%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e2,330,222,475\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e49,740,291\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.09%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e51,330,931\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e811,167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.56%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e97,583,203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e509,095\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e0.52%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eNE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e175,205,042\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e2,409,900\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.36%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e407,910,324\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e9,181,513\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eNH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e99,189,168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e1,155,423\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e252,367,553\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e6,534,634\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.52%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eNJ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,404,537,336\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e37,036,092\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.57%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e1,631,943,418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e42,017,599\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.51%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eNM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e429,330,157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e5,500,046\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.26%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e506,186,137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e8,597,409\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.67%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eNV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e473,843,553\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e13,139,151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.70%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e559,395,326\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e14,216,542\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.48%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eNY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e5,829,268,514\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e144,150,306\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.41%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e6,764,122,830\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e150,821,061\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.18%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eOH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e3,402,230,358\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e86,828,604\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.49%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e4,176,140,791\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e103,453,544\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.42%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eOK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e482,998,932\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e17,148,816\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e3.43%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e856,691,371\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e15,744,203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.80%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e692,460,900\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e15,425,390\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.18%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e788,742,202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e14,385,851\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.79%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e3,160,940,780\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e75,388,299\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e3,508,116,320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e72,142,517\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.02%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e216,309,688\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e3,031,424\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.38%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e339,266,810\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e1,175,048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e0.35%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e526,662,256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e21,495,162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e3.92%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e703,446,267\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e20,427,021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.82%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e98,848,284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e3,403,779\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e3.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e156,941,497\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e6,293,466\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e3.86%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,020,077,285\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e25,741,369\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.46%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e1,437,957,588\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e37,512,074\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e2.54%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eTX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e3,288,329,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e104,535,086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e3.08%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e3,793,302,258\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e147,947,276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e3.75%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eUT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e190,228,381\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e2,136,774\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.11%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e477,031,534\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e9,263,434\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e920,439,229\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e24,277,717\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.57%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e5,077,628,513\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e68,847,989\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.34%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eVT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e159,336,717\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e2,205,689\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.37%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e194,264,134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e673,315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e0.35%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eWA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,133,992,690\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e27,652,117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.38%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e1,510,240,192\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e20,737,221\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.35%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eWI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e1,143,138,974\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e22,556,271\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.94%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e1,929,066,883\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e15,537,415\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e0.80%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eWV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e583,436,427\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e9,040,465\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e1.53%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e849,891,110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e9,347,537\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.09%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003eWY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e35,128,447\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e848,914\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.36%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e45,588,404\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e792,842\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.71%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 3.0237%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7.5915%;\"\u003e\n \u003cp\u003e58,192,270,885\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 6.6265%;\"\u003e\n \u003cp\u003e1,481,601,770\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 4.6321%;\"\u003e\n \u003cp\u003e2.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 7.0125%;\"\u003e\n \u003cp\u003e75,788,508,629\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 6.2405%;\"\u003e\n \u003cp\u003e1,624,480,152\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"bottom\" style=\"width: 4.3104%;\"\u003e\n \u003cp\u003e1.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"bottom\" style=\"width: 30.4766%;\"\u003e\n \u003cp\u003e* State reported drug utilization for covered outpatient drugs paid for by state Medicaid agencies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"bottom\" style=\"width: 46.5139%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;data downloaded from https://www.medicaid.gov/medicaid/prescription-drugs/state-drug-utilization-data/index.html\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"bottom\" style=\"width: 39.6945%;\"\u003e\n \u003cp\u003e**Accelerated Approval and conversion dates from \u003cstrong\u003eAA Orphan approval list 1.11.23.xlsx\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"bottom\" style=\"width: 35.1267%;\"\u003e\n \u003cp\u003eInflation adjusted using GDP price deflator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 1.0294%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 1.0294%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 2.4447%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Accelerated Approval Drugs to Treat Rare Diseases as Percent Total State Drug Spending, 2017-2022 (inflation adjusted)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"622\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedicaid Non-Accelerated Rx\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedicaid Accelerated Rx\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of State Medicaid\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedicaid Non-Accelerated Rx\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedicaid Accelerated Rx\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of State Medicaid\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eAK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e158,848,296\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e2,472,933\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.53%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e203,482,175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e3,120,549\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.51%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e799,705,246\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e34,232,561\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e4.10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e974,574,474\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e21,235,212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.13%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eAR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e448,944,774\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e8,923,938\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.95%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e494,761,814\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e7,503,590\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.49%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eAZ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,432,220,456\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e31,833,917\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1,726,813,636\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e50,151,045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.82%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e9,373,714,818\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e242,002,410\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.52%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e11,050,383,098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e288,718,646\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.55%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eCO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,069,058,885\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e17,462,106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.61%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1,389,020,919\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e15,621,678\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,428,588,828\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e17,954,842\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.24%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1,721,193,087\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e16,732,858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.96%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e319,507,950\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e2,214,532\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e240,076,443\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e770,392\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.32%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eDE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e31,448,217\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e82,035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.26%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e266,416,852\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e5,368,026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.98%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eFL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e3,352,151,245\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e127,329,365\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e3,593,360,159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e126,208,612\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.39%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,323,233,317\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e52,570,982\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.82%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1,342,163,340\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e37,201,625\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.70%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eHI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e238,948,030\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e4,237,711\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e215,265,723\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e3,481,418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.59%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e421,229,662\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e13,539,768\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.11%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e741,374,072\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e14,635,626\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.94%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eID\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e224,240,500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e3,937,071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.73%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e532,505,781\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e10,332,580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e2,288,305,053\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e67,092,181\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e2,888,829,014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e71,208,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.41%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eIN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,751,700,288\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e66,780,198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.67%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e2,380,027,693\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e81,934,472\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eKS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e423,748,356\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e11,717,803\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e265,320,232\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e14,287,414\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e5.11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eKY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,464,929,162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e17,148,505\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.16%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1,993,529,599\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e22,454,729\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eLA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,229,225,918\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e27,263,180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e2,396,713,286\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e35,724,781\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.47%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,684,186,355\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e26,487,538\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.55%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e2,127,942,062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e28,777,999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,322,818,449\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e20,905,975\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.56%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1,606,950,641\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e26,324,313\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.61%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eME\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e259,448,339\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e3,291,620\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e452,294,704\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e6,257,270\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.36%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e2,567,934,121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e59,900,694\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.28%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e3,223,190,796\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e58,042,022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.77%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eMN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,135,831,465\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e34,080,432\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.91%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1,319,090,214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e36,312,740\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.68%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eMO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,433,366,878\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e31,011,642\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.12%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1,484,972,316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e38,580,583\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.53%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e509,844,422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e18,051,575\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.42%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e408,158,185\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e8,318,943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eMT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e240,614,036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e6,807,215\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e394,794,601\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e7,342,098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.83%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eNC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e2,077,729,519\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e48,411,416\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.28%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e2,330,222,475\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e49,740,291\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.09%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e61,285,303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e968,473\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.56%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e97,583,203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e509,095\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.52%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eNE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e209,181,754\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e2,877,241\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.36%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e407,910,324\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e9,181,513\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eNH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e118,424,469\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1,379,489\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e252,367,553\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e6,534,634\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.52%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eNJ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,676,912,833\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e44,218,332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.57%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1,631,943,418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e42,017,599\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.51%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eNM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e512,588,191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e6,566,644\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.26%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e506,186,137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e8,597,409\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.67%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eNV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e565,733,865\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e15,687,166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.70%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e559,395,326\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e14,216,542\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.48%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eNY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e6,959,711,885\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e172,104,715\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.41%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e6,764,122,830\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e150,821,061\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.18%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eOH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e4,062,009,326\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e103,666,878\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.49%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e4,176,140,791\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e103,453,544\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.42%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eOK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e576,664,705\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e20,474,408\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.43%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e856,691,371\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e15,744,203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.80%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e826,746,676\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e18,416,765\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.18%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e788,742,202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e14,385,851\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.79%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e3,773,927,564\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e90,008,007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e3,508,116,320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e72,142,517\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.02%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e258,257,635\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e3,619,294\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.38%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e339,266,810\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1,175,048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.35%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e628,795,457\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e25,663,621\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.92%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e703,446,267\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e20,427,021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.82%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e118,017,480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e4,063,858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e156,941,497\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e6,293,466\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.86%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,217,896,205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e30,733,275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.46%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1,437,957,588\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e37,512,074\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.54%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eTX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e3,926,019,598\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e124,807,098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.08%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e3,793,302,258\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e147,947,276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e3.75%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eUT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e227,118,500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e2,551,149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.11%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e477,031,534\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e9,263,434\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,098,935,797\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e28,985,784\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.57%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e5,077,628,513\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e68,847,989\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.34%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eVT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e190,236,158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e2,633,428\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.37%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e194,264,134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e673,315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.35%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eWA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,353,902,704\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e33,014,565\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.38%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1,510,240,192\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e20,737,221\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.35%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eWI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1,364,822,684\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e26,930,505\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.94%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e1,929,066,883\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e15,537,415\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e0.80%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eWV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e696,579,583\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e10,793,641\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.53%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e849,891,110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e9,347,537\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.09%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 37px;\"\u003e\n \u003cp\u003eWY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 129px;\"\u003e\n \u003cp\u003e41,940,746\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1,013,540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e2.36%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 115px;\"\u003e\n \u003cp\u003e45,588,404\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003e792,842\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e1.71%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTotal \u0026nbsp; \u0026nbsp; \u0026nbsp; $69,477,231,703 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; $1,768,922,021 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; $83,827,252,056 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; $1,862,546,188\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Accelerated Approval Drug Spending to Treat Rare Disease as Percent total State Medicaid Spending, 2017-2022\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote: In calculating percentage of spending, Total Medicaid Spending (denominator) includes drug rebates, but the spending on rare disease AA drugs (numerator) does not include rebates as the information is not available.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"257\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 193px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRare Drug Accelerated Approval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 193px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpending as Percent State Medicaid Spending\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eAK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.321\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.532\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e1.655\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.346\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eAR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.483\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.451\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eAZ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.909\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.453\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.562\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.715\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eCO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.424\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.379\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.476\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.091\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eDE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.583\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eFL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e1.148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.180\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e1.295\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.960\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eHI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.424\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.388\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.724\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.831\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eID\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.593\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.492\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eIL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.919\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.781\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eIN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e1.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2.048\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eKS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.667\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eKY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.654\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.891\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eLA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.689\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.187\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.272\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.363\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.385\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.536\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eME\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.288\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.651\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.614\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.127\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eMN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.554\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.630\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eMO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.675\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.341\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e1.043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.877\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eMT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e1.485\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.648\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eNC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.881\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.161\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eNE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.916\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eNH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.719\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eNJ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.394\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.597\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eNM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.473\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.672\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eNV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e1.396\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.225\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eNY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.516\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eOH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e1.156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.425\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eOK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.924\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.250\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.667\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.454\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.665\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.536\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e1.193\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.135\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.917\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.626\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.765\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.177\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eTX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.818\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eUT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.274\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.955\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.523\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.200\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eVT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eWA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.377\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eWI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.428\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eWV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e1.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.098\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eWY\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.278\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0.282\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAverage \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;0.67% \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;0.84%\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Approval \u0026nbsp;N/A\u003c/p\u003e\n\u003cp\u003eConsent N/A\u003c/p\u003e\n\u003cp\u003eData Availability: Upon request from Dr. Thorpe\u003c/p\u003e\n\u003cp\u003eFunding: To Dr.Thorpe from EveryLife Foundation for Rare Diseases\u003c/p\u003e\n\u003cp\u003eContributions; The design and analysis was conducted by Dr Thorpe the co-authors contributed to the interpretation and implications and discussion.\u003c/p\u003e\n\u003cp\u003eAcknowledgments: The authors thanks Annie Kennedy and Peter Joski for their contributions to the paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ehttps://www.macpac.gov/wp-content/uploads/2022/12/MACSTATS_Dec2022_WEB-508.pdf at Exhibit 18.\u003c/li\u003e\n\u003cli\u003eAccessed on March 3, 2023 at https://www.fda.gov/media/151146/download\u003c/li\u003e\n\u003cli\u003eFDA Guidance for Industry: Expedited Programs for Serious Conditions\u0026mdash;Drugs and Biologics. May 2014. Available from: https://www.fda.gov/files/drugs/published/Expedited-Programs-for-Serious-ConditionsDrugs-and-Biologics.pdf.\u003c/li\u003e\n\u003cli\u003eFDA. Accelerated Approval. Jan. 4, 2018. Available from: https://www.fda.gov/patients/fast-trackbreakthrough-therapy-accelerated-approval-priority-review/accelerated-approval.\u003c/li\u003e\n\u003cli\u003eFood and Drug Administration Regulatory Modernization Act of 1997.\u003c/li\u003e\n\u003cli\u003eFood and Drug Administration Safety and Innovation Act of 2012 (FDASIA)\u003c/li\u003e\n\u003cli\u003eThe Grace Yang, Inna Cintina, Anne Pariser, Elisabeth Oehrlein, Jamie Sullivan, Annie Kennedy. \u003cstrong\u003eThe national economic burden of rare disease in the United States in 2019\u003c/strong\u003e, Orphanet Journal of Rare Diseases, April 2022\u003c/li\u003e\n\u003cli\u003eAccessed on March 1 at https://www.macpac.gov/publication/high-cost-specialty-drugs-moving-towards-recommendations/\u003c/li\u003e\n\u003cli\u003eSachs R, Donohue J, Dusetzina S. Reforming Reimbursement for the US Food and Drug Administration\u0026rsquo;s Accelerated Approval Program to Support State Medicaid Programs. \u003cem\u003eJAMA Health Forum. \u003c/em\u003e2022: 3(11):e224115. doi 10.001/jamahealthforum.2022.4115\u003c/li\u003e\n\u003cli\u003e* state reported drug utilization for covered outpatient drugs paid for by state Medicaid agencies \u003cem\u003edata downloaded from \u003c/em\u003e\u003cem\u003ehttps://www.medicaid.gov/medicaid/prescription-drugs/state-drug-utilization-data/index.html\u003c/em\u003e\u003c/li\u003e\n\u003cli\u003e\u003cem\u003edata downloaded from \u003c/em\u003e\u003cem\u003ehttps://www.medicaid.gov/medicaid/prescription-drugs/state-drug-utilization-data/index.html\u003c/em\u003e\u003c/li\u003e\n\u003cli\u003eThese data are available from: https://www.macpac.gov/wp-content/uploads/2022/12/MACSTATS_Dec2022_WEB-508.pdf and https://www.macpac.gov/wp-content/uploads/2018/12/December-2018-MACStats-Data-Book.pdf\u003c/li\u003e\n\u003cli\u003ehttps://www.macpac.gov/wp-content/uploads/2022/12/MACSTATS_Dec2022_WEB-508.pdf at Exhibit 18.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Non-oncology rare disease medications, role in the level and growth in Medicaid spending","lastPublishedDoi":"10.21203/rs.3.rs-4612847/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4612847/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe accelerated approval pathway allows drugs for serious conditions that fill an unmet medical need to be approved based on a surrogate or intermediate clinical endpoint that is reasonably likely to predict a clinical benefit. The accelerated approval process has come under criticism from some state Medicaid programs who have sought to exclude paying for medications approved through this process.\u003c/p\u003e\n\u003cp\u003eTo examine the role that non-oncology rare disease drug spending assumes in state Medicaid programs, we examined state spending and changes in spending on the medications overall and as a percent of total state Medicaid spending in 2017 and 2022.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn average nationally, pre-rebate spending on accelerated approval drugs to treat non-oncology rare diseases accounted for only 0.67 percent of state Medicaid spending in 2017 and 0.84 percent in 2022. In 2017 this ranged from a low of 0.008 percent in Delaware to a high of 1.7 percent in Indiana. The results were nearly identical in 2022.\u003c/p\u003e\n\u003cp\u003eThese medicines are neither a primary driver of state Medicaid spending or spending growth, nor an effective target for reform.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEfforts to reduce the level and growth in Medicaid spending need to target the key drivers—dual eligible and the disabled populations that account for a third of Medicaid spending.\u003csup\u003e1 \u0026nbsp;\u003c/sup\u003eThis would include providing more social services to address the determinants of health, integration of care coordination between Medicare and Medicaid and more efficient integration of the funding flows. Quite clearly, accelerated approval medications for non-oncology drugs to treat rare diseases are not contributing to the level and growth in Medicaid spending.\u003c/p\u003e","manuscriptTitle":"The Role of Accelerated Approval Drug Spending on Medicaid Spending to Treat Rare Diseases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-17 10:21:59","doi":"10.21203/rs.3.rs-4612847/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"51b35ffa-0df2-4f55-a16f-6f0df568cd91","owner":[],"postedDate":"March 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-15T16:27:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-17 10:21:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4612847","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4612847","identity":"rs-4612847","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}