New federalism and health care policy: states and the old questions

The New Federalism that evolved under the Reagan administration tends to grant states more discretion in the implementation of health care programs. It thereby rekindles old concerns about the commitment, capacity, and progressivity of the states. This paper reviews recent policy developments and reconsiders state performance from the vantage point of the mid-1980s. While hard evidence remains elusive, a plausible case exists that any gap between the states and Washington on commitment, capacity, and progressivity has diminished. State administrative capacity in particular has probably increased. The continued presence of substantial variation among the states needs to be underscored, however. Moreover, the relentless imperative of economic development, or migration, theory sets severe limits on how far states can go in adopting redistributive measures to assure adequate medical care for the poor. Given current federal laws, the most optimistic, plausible scenario envisions the rise of a technical politics of efficiency in the states. In spite of state limitations, health policy reformers need to pay increased attention to their potential role.     

The impact of public health care financing policies on private-sector hospital costs

Two of the best-known economic models of hospital behavior are utilized to examine theoretically the issue of cross-subsidization of hospital costs between public and private-pay patients. It is shown that the existence of public/private hospital-charge differentials does not, in itself, demonstrate that public programs are subsidized by the private sector. This differential is to be expected, whether hospitals are considered to be monopolistic profit maximizers or controlled by physicians. While cost-based hospital reimbursement may be dynamically inefficient, it is shown to have certain static efficiency properties when hospitals provide services to both public and private patients.     

The distribution of health care financing in the overall population and among the elderly

This paper focuses on the distribution of health care costs among the elderly. Four revenue sources are considered: income taxes, payroll taxes, user fees, and insurance premiums. The empirical work shows that the heavy reliance on direct payments as a means of collecting revenues among the elderly makes their contribution to the health care financing structure more regressive than for the nonelderly.     

The political and economic context of mental health care in the United States

Since the mid-1970s, the mental health treatment system in the U.S. has faced budgetary famine. This is in stark contrast to the growing cornucopia of fiscal resources enjoyed by the overall health care system. This paper explores the complex reasons for this disproportionate allocation in health spending. On the one hand, mental health may suffer from the perception that its diagnoses are largely "subjective" and its treatments do not fit the traditional "medical model" that can be defined precisely and paid for by third-party insurers. But more importantly, the death of mental health resources can be attributed to the peculiar nature and characteristics inherent in American politics. This paper describes the American political environment, from both a historical and a contemporary perspective, to give some insight into the development of policies affecting the mental health system in the U.S. Given the current climate of fiscal conservatism in this country toward any increases in social spending, it is likely that the profound mismatch in need and spending for mental health programs will continue indefinitely.     

Maternity care financing: universal access or universal care?

In an era of fiscal constraint, growing poverty, increased uninsuredness, medical liability problems, and increasing costs of maternity care, public and private financing mechanisms are changing rapidly and the service delivery system is increasingly fragmented. Despite the almost mercurial changes in the system, data from national studies show that access to care is a major problem affecting all childbearing women. This paper describes the three groups of women who require comprehensive maternity care, their insurance coverage, and the gaps for each group. It describes proposals which are currently under development to reduce uninsuredness and produce universal access and, in addition, presents an alternative plan for universal maternity care.     

The federalism dimension of proportionality

EU Treaties contain an arsenal of purpose-defined and ambiguous competences that are enjoyed by EU institutions, yet devote little attention to the restraining impact of EU competences on Member States' autonomy and policies. While the focus has traditionally been on subsidiarity to deal with competence issues, the judgment of the Bundesverfassungsgericht in Weiss revitalises the discussion on the potential of proportionality to guide competence issues. This inquiry seeks to highlight both the existing traces of competence proportionality employed by the Court to allocate competences as well as the potential of the proportionality standard to temper the spillovers on Member States' autonomy accruing from the exercise of EU competences. While the Treaty restricts proportionality to reviewing the use (not existence) of EU competences, the Court has implicitly employed proportionality considerations to verify the existence of EU competences. In addition, drawing from established case law, competence proportionality assessments could rely on an effect-based substantive review in combination with procedural duties allowing a meaningful balancing of national autonomy against the dynamics of deeper integration.     

Medicare and Medicaid programs; health care financing issues; solicitation of applications for a research center--HCFA. General notice

HCFA is soliciting applications for a research center to participate in the study of health care financing issues. This project will be funded under the Cooperative Research or Demonstration Projects provisions of section 1110 of the Social Security Act. This solicitation contains information about research center functions, project requirements, application procedures, criteria to be used in reviewing applications, and the amount and duration of awards.