Medicaid,the States and Health Care Reform

Health care reform in the US is relying extensively on Medicaid for achieving universal health coverage. This article addresses the question of whether Medicaid is an appropriate foundation for reducing the ranks of the uninsured, given its dependence on economic conditions and the vulnerability of state budgets, along with the ever-changing preferences of governors and legislators. This article assesses the effects of the ebb and flow of Medicaid policy-making on at‐risk populations and what this implies for the Affordable Care Act. By establishing a nationwide income floor at 133% of the Federal Poverty Level, the legislation eliminates eligibility inequities across the states. However, it is argued that when state budgets are strained, as they undoubtedly will be when the reform bill is fully implemented, local officials will downsize benefit packages, raise co-payments, mandate more managed care, and reduce provider payments, negatively affecting the availability, scope, and quality of services.     

Assessing Medicaid managed care in eastern state.

This case examines the expanding role of managed care programs in improving health care for the poor while controlling runaway health care costs. The case asks what the commissioner of health in a large eastern state should do to effectively monitor Medicaid managed care programs in her state. The commissioner faces intense pressures for cost containment and strong, but not universal, support for the managed care solution to health care cost problems. The commissioner is herself concerned that the cost savings attributed to managed care may not be real and that the unintended effects on health care may be adverse. Her immediate challenge is to determine what kinds of data she should require service providers to submit to her agency so that she may effectively monitor managed care programs for health care quality, provide positive feedback to health care providers, and establish politically credible program oversight.     

Assessing medicaid managed care in eastern state

This case examined the expanding role of so-called managed care programs in improving health care for the poor while controlling runaway health care costs. The case asked what the commissioner of health, Dr. Lorna Hill, in a large eastern state should do to effectively monitor Medicaid managed care programs in her state. The commissioner faced intense pressures for cost containment and strong, but not universal, support for the managed care solution to health care cost problems. The commissioner was herself concerned that the cost savings attributed to managed care might not be real and the unintended effects on health care might be adverse. Her immediate challenge was to determine what kinds of data she should require service providers to submit to her agency so that she could effectively monitor managed care programs for health care quality, provide positive feedback to health care providers, and establish politically credible program oversight.     

Health Care Reform in China: An Analysis of Development Trends and Lack of Implementation

ABSTRACT

China's health care system, under the direction of the central government, has undergone continuous reform in recent decades. Many problems have been encountered, with successive measures attempting to deal with shortcomings and failings of previous reforms. To what extent can implementation failures account for the recurring problems, and what explains these failures? The analysis adopts the theoretical lens of structural-instrumental and cultural-institutional perspectives, respectively, and draws also on recent developments in implementation theory. The historical trajectory of health reform is described, with particular reference to why health policies formulated by the central government during different periods repeatedly failed to achieve their objectives. The empirical analysis finds that structural factors, such as departmentalism and regional separation resulting in complex, overlapping horizontal and vertical actor patterns, have been a primary reason for implementation failures and suggests that they will continue to dog future reform efforts.     

Medicaid Managed Care for Children with Special Health Care Needs: Examining Legislative and Judicial Constraints on Privatization

Over the past decade, much has been written about the results of reinventing government. Most research has examined the effects of executive or managerial perspectives. Using David Rosenbloom's competing perspectives model, we examine Medicaid managed care programs for children with special health care needs to illustrate the influence of legislative and judicial institutional perspectives on the reinvention movement. Legislative and judicial responses to the reinvention of Medicaid managed care reveal the outer limits of what managed care and related executive reforms can accomplish in a Constitutional system that is based on checks and balances among competing institutional perspectives. Furthermore, relative to Medicaid managed care, legislative and judicial responses conserve public responsibility to society's most vulnerable populations. In the long run, the balance of institutional perspectives and values—not managerial innovation per se—will influence public administration.     

Jump-Starting Collaboration: The ABCD Initiative and the Provision of Child Development Services through Medicaid and Collaborators

Many policy problems require governmental leaders to forge vast networks beyond their own hierarchical institutions. This essay explores the challenges of implementation in a networked institutional setting and incentives to induce coordination between agencies and promote quality implementation. It describes the national evaluation of the Assuring Better Child Health and Development program, a state-based program intended to increase and enhance the delivery of child development services for low-income children through the health care sector, using Medicaid as its primary vehicle. Using qualitative evaluation methods, the authors found that all states implemented programs that addressed their stated goals and made changes in Medicaid policies, regulations, or reimbursement mechanisms. The program catalyzed interagency cooperation and coordination. The authors conclude that even a modest level of external support and technical assistance can stimulate significant programmatic change and interorganizational linkages within public agencies to enhance provision of child development services.     

The Medicaid Mandates of the 1980s: An Intergovernmental Perspective

Medicaid, the health care program for the poor, has undergone significant changes in the last fifteen years. Many of those changes relate to the intergovernmental nature of the program. Medicaid is jointly operated, with the federal and state governments sharing program costs. Despite a set of program guidelines dictated by the federal government, states have traditionally had substantial latitude in Medicaid decisions. However, a series of developments in the 1980s led to increasing constraints on state Medicaid discretion, including federal mandates to expand Medicaid coverage. This article examines the inception and effectiveness of the Medicaid mandates from the perspective of interstate equity of health care services for poor families.     

Medicaid in the 1990s: Trends, Innovations, and the Future of the "PAC-Man" of State Budgets

Rapidly escalating health-care inflation and congressionallymandated expansions have led to large increases in spendingfor Medicaid, the federal-state program of health care for thepoor. These increases came at a time when state budgets werealready under recession-induced stresses. In addition, 1991brought new pressures for Medicaid spending from the courtsand closer federal scrutiny and control over revenues used forthe program's state "match." Yet the Medicaid picture is farfrom bleak. Diversity, innovation, and an emerging stale policyrole also characterize the program in ways that epitomize thestrengths and weaknesses of the American intergovernmental system.     

The Impact of Welfare Reform on Medicaid

Welfare reform did not usher in comprehensive Medicaid reform,if "reform" is defined as dismantling the basic framework ordesign of the nations's health-care system for the poor. Instead,it left much of the previous Medicaid system intact. However,welfare reform has contributed to changes in the Medicaid-eligiblepopulations, greater variability and experimentation with stateMedicaid initiatives, and greater sate control over Medicaidprogram decisions. Thus, the welfare-reform movement clarifieda major trend in contemporary American politics—the increasein state discretion and flexibility in social welfare policymaking.The states are now at the center of Medicaid decisionmaking,and they are in a key position to determine the future directionof heath-care assistance for the poor in the United States.     

THE HEALTH CARE FINANCIAL CRISIS: REORGANIZATION AND EVIDENCE-BASED MEDICINE AS A RESPONSE TO AN "UNHOLY TRINITY"

The key issues of the health care system are often conceptualized as involving three basic dimensions: 1) the quality of health care provided, 2) access to the health care system, and 3) the cost of health care. Following two decades of rapidly escalating health costs throughout advanced industrial societies, the relationships among these three dimensions now constitute what has been called an “unholy trinity” in that improvements along one dimension will almost inevitably provoke problems in terms of one or both of the others. This symposium examines two distinct types of reform that have been developed in response to the crisis in health care costs. The first focuses upon attempts to reorganize existing institutions in order to make them more effective and cost‐efficient. The second considers the move toward “evidence‐based medicine,” that is, more critically evaluating health care outcomes to make sure that treatments are effective and cost‐efficient.     

The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions

The U.S. population receives suboptimal levels of preventive care and has a high prevalence of risky health behaviors. One goal of the Affordable Care Act (ACA) was to increase preventive care and improve health behaviors by expanding access to health insurance. This paper estimates how the ACA‐facilitated state‐level expansions of Medicaid in 2014 affected these outcomes. Using data from the Behavioral Risk Factor Surveillance System, and a difference‐in‐differences model that compares states that did and did not expand Medicaid, we examine the impact of the expansions on preventive care (e.g., dental visits, immunizations, mammograms, cancer screenings), risky health behaviors (e.g., smoking, heavy drinking, lack of exercise, obesity), and self‐assessed health. We find that the expansions increased insurance coverage and access to care among the targeted population of low‐income childless adults. The expansions also increased use of certain forms of preventive care, but there is no evidence that they increased ex ante moral hazard (i.e., there is no evidence that risky health behaviors increased in response to health insurance coverage). The Medicaid expansions also modestly improved self‐assessed health.     

Health Care Reform in Britain and Germany: Recasting the Political Bargain with the Medical Profession

Health care systems in the postwar period have been governed by political bargains between the state and the medical profession that have delinzated their respective powers and jurisdictions. Recent health care cost containment reforms in Britain and Germany are altering these bargains, and thereby challenge the prerogatives and autonomy of the medical profession in health policy formulation and in administration of the health care systems. But these challenges to doctors' power and autonomy vary between the two countries. Britain's 1989 “internal market” reforms attack the corporatist bargain with physicians by introducing market mechanisms into the National Health Service and, at the same time, strengthening central state control of the health care system. In Germany, on the other hand, the government's 1992 reforms only partially breached the corporatist bargain with doctors in order to strengthen rather than destroy this governance arrangement. The government has tried to curb what it views as excessive power of doctors while still allowing them a significant degree of corporatist self-governance. The reform efforts in both countries highlight some of the problems with different governance arrangements in health care systems and, more specifically, the difficulties associated with a market in health care.     

The Public’s Anger: White Racial Attitudes and Opinions Toward Health Care Reform

Pundits and politicians debated whether race was implicated in the rancorous public forums and demonstrations over health care reform. Research suggests that for many white Americans, racial predispositions play a greater role in their opinions on health care than non-racial predispositions. Building on this work, I examine the extent to which anger uniquely activates white racial attitudes and increases their effect on preferences for health care reform. My theory suggests this effect occurs because anger and thoughts about race are tightly linked in memory. Using a nationally representative experiment over two waves, I induced several emotions to elicit anger, fear, enthusiasm, or relaxation. The results show that anger uniquely pushes racial conservatives to be more opposing of health care reform while it triggers more support among racial liberals. On the other hand, anger does not enhance the effect of race-neutral principles on health care reform.     

Medicaid matters: children's health and Medicaid eligibility expansions.

In the late 1980s, a series of federal laws were enacted which expanded Medicaid eligibility to more of the nation's children. States had a great amount of discretion in how fast and how far these expansions were implemented. As a result, there was great variation among the states in defining who was eligible for the program. This variation provides a rare opportunity to disentangle the effect of Medicaid from a child's socioeconomic status. Using data from the National Health Interview Survey, we address whether the Medicaid expansions improved the health and functional status of children. Econometric models were developed using fixed-effects regressions, and were estimated separately for white, black, and Hispanic children. White children experienced statistically significant reductions in acute health conditions and functional limitations. Black and Hispanic children showed some evidence of improved health conditions and functional status, but this evidence is inconclusive in the study sample. This may be due to differences in their access to appropriate health services or to the smaller sample size of minorities in each geographic area. The findings are also relevant to the implementation of the Children' Health Insurance Program (CHIP), the latest federal effort to expand access to health care to poor and near poor children. In many states, CHIP is being implemented in whole or in part through further Medicaid expansions.     

MANAGED COMPETITION IN FLORIDA HEALTH CARE: ITS STRENGTHS AND WEAKNESSES

Managed competition in health care is a model for reform that has been adopted by several states and considered as a model for national health care reform. This article assesses the strengths and weaknesses of managed competition in Florida based on the responses of essential participants in the managed competition network and data from network documents. Results of the analysis reveal that the strength of the reform has been in offering small employers and their employees a wide choice of health care insurance and in providing them with information to make informed health insurance choices. In addition to increasing choice and information, the managed competition network has become the small group insurance industry watchdog, applying pressure to keep the market fair and functioning. However, cost control difficulties and a continued limited access to health insurance demonstrate the weaknesses of the Florida reform. The article concludes by discussing the politicization of health care reform in Florida and the future of this reform effort in a changing political climate.     

Income, assets, and health insurance: economic resources for meeting acute health care needs of the aged.

In this article, the authors use data from the Survey of Income and Program Participation (SIPP) to examine the relationship between economic resources and acute health care needs among the aged. The circumstances of individuals who rely on Medicare as their only form of health insurance are considered in detail because they are potentially more vulnerable when faced with health care expenses. Particular attention is given to the amount of family income and personal contingency assets held by this group and the level of out-of-pocket liability for acute care they might have been expected to face in 1984. The authors point out that their research findings would be strengthened by linkage of a more current SIPP data set to Medicare program records and the development of Medicaid eligibility simulation capability in the SIPP context.     

THE STATES' ROLE IN HEALTH CARE COST CONTAINMENT*

Under the Social Security Act of 1935, the federal government expanded its involvement in maternal and child health care programs through grants-in-aid to state and local health departments. The Medicaid legislation of 1965 vastly enlarged federal expenditures, and state responsibilities. State performance was frequently criticized, especially in health care cost containment. Recently, the states have initiated several efforts to link cost containment and the quality of health care.     

Stigma and other determinants of participation in TANF and Medicaid.

We developed a conceptual framework to examine the association between stigma, enrollment barriers (e.g., difficult application), knowledge, state policy, and participation in the Temporary Assistance to Needy Families (TANF) and adult Medicaid programs. Survey data from 901 community health center patients, who were potential and actual participants in these programs, indicated that while images of the Medicaid program and its recipients were generally positive, stigma associated with welfare stereotypes reduced both TANF and Medicaid enrollment. Expectations of poor treatment when applying for Medicaid, enrollment barriers, and misinformation about program rules were also associated with reduced Medicaid enrollment. States that enacted strict welfare reform policies were potentially decreasing TANF participation, while states with more simplified and generous programs were potentially increasing Medicaid participation. The results suggest that the image of the adult Medicaid program remains tied to perceptions about welfare and provides guidance to policymakers about how to improve participation rates.     

State health reform: Effects on labor markets and economic activity

Individual states are actively weighing health care reform proposals and their potential impacts on many levels, including states' own economies. This article considers the effects on state economies of two instruments of health reform: employer mandates and cost containment. The literature suggests that an employer mandate will reduce employees' wages in the long run. In the short run, however, to compensate for the costs associated with mandated health care insurance for their employees, firms may raise their prices to consumers, reduce the number of employees or allow a drop in profit margins. By increasing health care spending and the number of insured persons, mandates would also increase states' levels of economic activity. Though cost containment may dampen the stimulative effects of expanded coverage, resources not spent on health care as a result of effective cost containment might be redistributed to other sectors in a state's economy.     

The decentralization of primary health care delivery in Chile

The article argues that during the 1980s the process of decentralization in Chile under the military government of General Pinochet shifted the delivery of primary health care to the municipal level. Despite the return to more democratic forms of government in 1990 the overall structure of local‐level service delivery has remained largely unchanged. The municipalities have retained responsibility for service delivery but resources remain centrally determined. In an attempt to enhance accessibility, choice and the responsiveness of the system to individual and local need, reform has been made to the financial transfer mechanisms and a new model of primary health care delivery has recently been introduced. However, problems of resourcing and implementation limit the effectiveness of some of the changes that have accompanied decentralization. Problems have resulted in primary health care delivery because administrative decentralization has not been accompanied by fiscal decentralization, nor effective political decentralization. Copyright © 2001 John Wiley & Sons, Ltd.