Executive federalism and Medicaid demonstration waivers: implications for policy and democratic process

Executive federalism emphasizes collaboration between the executive branches at the national and state levels to transform grant programs through the implementation process. In this regard, Medicaid demonstration waivers loomed large during the presidencies of Bill Clinton and George W. Bush. This article documents and compares the volume and substance of section 1115 Medicaid waiver activity under the two presidencies. From the perspective of policy performance, Medicaid demonstration waivers provide modest support for the view that states serve as laboratories for policy learning in the health care arena. More broadly, the waivers have not yielded a major solution to the problem of the uninsured and are unlikely to do so. At the same time, they have not (as some have suggested) been a subterranean force for the erosion of Medicaid. To the contrary, these waivers have often enhanced health services for low-income people; above all, they have helped preserve Medicaid as an entitlement by undercutting support for those seeking to convert the program into a block grant. From the perspective of the democratic process, we find that Congress has been a more significant player in shaping waivers than the executive federalism model suggests. While the decision processes surrounding Medicaid waivers often fall short of democratic standards with respect to transparency and opportunities for public input, they still compare favorably to certain alternatives.     

Physician participation in Medicaid: background and issues

Most Americans gain entry into the medical care system through office-based primary care physicians. The Medicaid program was created in 1965 in part to increase the access of low-income people to medical services in that mainstream. But, over the years, office-based physicians have reduced their treatment of Medicaid patients, and many have withdrawn from the program altogether. The result is not only that the original programmatic goal has not been fully achieved, but also that the costs of the program are higher than they would be otherwise. In this article, the importance of Medicaid participation by office-based primary care physicians is described, and a number of obstacles to their participation are identified. The obstacles include state policies regarding eligibility, coverage, and provider compensation. The article recommends actions pertaining to these policies that might increase participation.     

Medicare and Medicaid programs: hospice conditions of participation. Final rule

This final rule revises the existing conditions of participation that hospices must meet to participate in the Medicare and Medicaid programs. The final conditions address the comments that we received on the proposed rule published on May 27, 2005. This final rule focuses on the care delivered to patients and their families by hospices and the outcome of that care. The final requirements continue to reflect the unique interdisciplinary view of patient care and allow hospices flexibility in meeting quality standards. These changes are an integral part of the Administration's efforts to achieve broad based improvements in the quality of health care and our efforts to improve the quality of care furnished through the Medicare and Medicaid programs.     

Medicare and Medicaid programs; revisions to conditions of participation for hospitals--HCFA. Final rule

This final rule establishes as a condition of participation (which facilities must meet in order to participate in the Medicare and Medicaid programs) the requirement that hospitals have a discharge planning process for patients who require such services and specifies the elements of that process. It also changes the required qualifications of a hospital's medical director. These provisions implement sections 9305(c) of the Omnibus Budget Reconciliation Act of 1986 (OBRA '86) and 6025 of the Omnibus Budget Reconciliation Act of 1989. Also, we are not adopting several minor proposed revisions to the conditions for coverage of suppliers of end-stage renal disease (ESRD) services. We are now developing comprehensive revisions to the ESRD regulations and believe that it would be appropriate to reconsider the proposed changes as part of that rulemaking process.     

Children's testimony: Research findings and policy implications

Abstract

Traditionally the British legal system has taken a sceptical attitude toward the testimony of children, reflected in the competency requirement, the corroboration rule and the judicial caution. However, recent psychological research has suggested that children, properly interviewed, can provide invaluable testimony in securing convictions in cases of sexual or physical abuse. Research suggests that children's spontaneous accounts of events are generally accurate, and that suggestibility can be greatly reduced by appropriate questioning techniques. Partly as a result of such research, the legal hurdles surrounding children's evidence have been dismantled and procedural innovations, such as the use of the Videolink and videotaped interviews introduced. Empirical research demonstrates the success of the Videolink and a similar evaluation is planned for videotaped interviews. The latter has highlighted the need for a new research agenda which would include the impact of biased or repeated questioning, and requests to children from abusers to lie or keep secrets.     

PPS waivers: implications for Medicare, Medicaid, and commercial insurers

This paper compares the Medicare prospective payment system (PPS) to four all-payer rate-setting systems that operated under HCFA waiver authority. The study examines the experience of Medicare, Medicaid, and commercial insurers under the two approaches. Data from several American Hospital Association surveys and from Medicaid 2082 report forms are analyzed. The paper concludes that the all-payer waiver programs have been as successful as PPS in controlling the rate of growth in Medicare costs. In addition, Medicaid programs are more successful in controlling their outlays in all-payer rate-setting environments than when they "go alone." Finally, there is no evidence to suggest that hospitals can increase charges in response to greater financial need under either PPS or the state waivers. Nevertheless, it appears that commercial insurers are better able to compete with Blue Cross plans in all-payer rate-setting states than elsewhere.     

Medicare and Medicaid programs; hospital conditions of participation: patients' rights. Final rule

This final rule finalizes the Patients' Rights Condition of Participation (CoP) which is applicable to all Medicare- and Medicaid-participating hospitals and contains standards that ensure minimum protections of each patient's physical and emotional health and safety. It responds to comments on the following standards presented in the July 2, 1999 interim final rule: Notice of rights; exercise of rights; privacy and safety; confidentiality of patient records; restraint for acute medical and surgical care; and seclusion and restraints for behavior management. As a result of comments received, we have revised the standards regarding restraint and seclusion and set forth standards regarding staff training and death reporting.     

Medicare and Medicaid programs; hospital conditions of participation: laboratory services. Final rule

This final rule finalizes the hospital conditions of participation requirements for hospitals that transfuse blood and blood components. It requires hospitals to: Prepare and follow written procedures for appropriate action when it is determined that blood and blood components the hospitals received and transfused are at increased risk for transmitting hepatitis C virus (HCV); quarantine prior collections from a donor who is at increased risk for transmitting HCV infection; notify transfusion recipients, as appropriate, of the need for HCV testing and counseling; and extend the records retention period for transfusion-related data to 10 years. The intent is to aid in the prevention of HCV infection and to create opportunities for disease prevention that, in most cases, can occur many years after recipient exposure to a donor.     

试论我国非政府组织政策参与存在的问题、原因及路径选择

非政府组织参与政震的过程对于平衡多元社会利益,推动政府民主决策和科学决策并实现国家政治现代化,进而提升国家"软实力"具有重要意义.当前,我国非政府组织在政策参与中面临着法律体系不健全、运作资金不足、专业人才缺乏和监督乏力等现实问题,应该从法律、制度以及非政府组织自身建设等层面有针对性地予以应对,解决现实中可能出现的政府和市场的"双重失灵"问题,以期提高政府决策能力,推动我国公共管理的民主化和科学化.     

Water as a multi-dimensional value: implications for participation and transparency

The article co-authored by Marco Shouten and Klaas Schwartz is correct in arguing that water is a political issue and efforts to decentralize and privatize decision making as recommended by the World Bank will not take the politics out of water. At the same time, this review advocates a broadened understanding of the water to include the cultural, ethical, environmental, and life-style dimensions of water. Only institutions that are inclusive, open, transparent, and accountable can bring legitimacy to decisions affecting the many conflicting water values with a realistic expectation of implementation.     

Children's Medicaid enrollment: the impacts of mandates, welfare reform, and policy delinking

From 1984 to 1990. Congress enacted a series of mandates that expanded Medicaid eligibility for low-income children by gradually delinking Medicaid eligibility from welfare eligibility. The 1996 national welfare reform law nominally completed the delinking process when the statutory phase-in of children's Medicaid coverage was preserved even as the states were given increased flexibility for administering welfare programs. This article provides estimates of the impact of these fedcral policy changes on children's Medicaid enrollment rates and analyzes the degree of success in uncoupling children's Medicaid enrollment from welfare. Data from the Current Population Survey for 1979 to 1998 are used to provide standardized enrollment probabilities for the United States and individual states. The results show important enrollment increases associated with the period of the mandated expansions, followed by enrollment declines associated with welfare reform. The largest increases in enrollment during this period were in states with historically restrictive welfare eligibility, but rates also rose in states that previously had relatively expansive welfare eligibility. The net effect was a reduction in the extent of state-to-state variation in enrollment. The Medicaid expansion peaked in 1995, prior to the advent of national welfare reform. Since then, children's Medicaid enrollment has fallen, with the largest declines falling on families with the very lowest incomes. Consistent with the desire to delink children's Medicaid coverage from welfare, the association between Medicaid and AFDC/TANF enrollment weakened during the expansionary period, but there still was a relatively strong relationship between policy outcomes for these two programs. Despite the policy changes, Medicaid coverage of children is still influenced by state-level welfare policy.     

Medicare and Medicaid programs; hospital conditions of participation: quality assessment and performance improvement. Final rule

This final rule requires hospitals to develop and maintain a quality assessment and performance improvement (QAPI) program. In the December 19, 1997 Federal Register, we published a proposed rule to revise the hospitals conditions of participation (CoPs). The QAPI CoP was one of the conditions included in the proposed rule. We separated the QAPI CoP from the larger set of hospital CoPs so that it could be published in advance of the remaining CoPs to implement the Administration's initiatives regarding medical errors. QAPI focuses provider efforts on the actual care delivered to patients, the performance of the hospital as an organization, and the impact of treatment furnished by the hospital on the health status of its patients. Specifically, it is important to note that a QAPI is not designed to measure a hospital's quality, but rather a minimum requirement that the hospital systematically examine its quality and implement specific improvement projects on an ongoing basis. State agencies (SAs) during their surveys, review all aspects of a hospital's operations and this review provides a framework in which the SA can assess a hospital's QAPI program. In addition, the QAPI entails all activities required for measuring quality of care and maintaining it at acceptable levels. This typically includes; 1) Identifying and verifying quality-related problems and their underlying cause; 2) Designing and implementing corrective action activities to address deficiencies; 3) Following up to determine the degree of success of an intervention and to detect new problems and opportunities for improvement. Performance improvement activities aim to improve overall performance assuming that there is no permanent threshold for good performance. Under performance improvement framework, hospitals will continuously study and improve the processes of healthcare and delivery of service.