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.     

Early Impacts of the Affordable Care Act on Health Insurance Coverage in Medicaid Expansion and Non‐Expansion States

The Affordable Care Act (ACA) aimed to achieve nearly universal health insurance coverage in the United States through a combination of insurance market reforms, mandates, subsidies, health insurance exchanges, and Medicaid expansions, most of which took effect in 2014. This paper estimates the causal effects of the ACA on health insurance coverage in 2014 using data from the American Community Survey. We utilize difference‐in‐difference‐in‐differences models that exploit cross‐sectional variation in the intensity of treatment arising from state participation in the Medicaid expansion and local area pre‐ACA uninsured rates. This strategy allows us to identify the effects of the ACA in both Medicaid expansion and non‐expansion states. Our preferred specification suggests that, at the average pre‐treatment uninsured rate, the full ACA increased the proportion of residents with insurance by 5.9 percentage points compared to 2.8 percentage points in states that did not expand Medicaid. Private insurance expansions from the ACA were due to increases in both employer‐provided and non‐group coverage. The coverage gains from the full ACA were largest for those without a college degree, non‐whites, young adults, unmarried individuals, and those without children in the home. We find no evidence that the Medicaid expansion crowded out private coverage.     

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.     

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.     

Locating the Issue Public: The Multi-Dimensional Nature of Engagement with Health Care Reform

This research examines in detail the structure of the issue public for health care reform, drawing from extensive, nationally representative survey data tapping general attentiveness to news and public affairs, specific interests in health care issues, and motivations (e.g., personal health and financial conditions) to follow health care reform issues. We furthermore adopt a multi-dimensional approach to defining the contours of the issue public for health care policy, separately studying its cognitive, affective, and behavioral underpinnings. Results indicate only weak interconnections across these dimensions—measured through health care knowledge, holding strong opinions on health care issues, and participation in health-related political activities, respectively—and somewhat different structural and motivational patterns underlying each. Theoretical, conceptual and methodological implications of these findings are discussed.Vincent Price and Joseph N. Cappella are Professors in the Annenberg School for Communication at the University of Pennsylvania, where Clarissa David, Brian Goldthorpe, and Marci McCoy Roth are doctoral students. Gathering of the data reported here was supported by grants to Vincent Price and Joseph N. Cappella from The National Science Foundation (Grant EIA-0306801) and the Annenberg Public Policy Center of the University of Pennsylvania. Views expressed are those of the authors alone and do not necessarily reflect opinions of the sponsoring agencies.     

Poorhouse to Warehouse: Institutional Long-Term Care in the United States

Nursing homes in the United States are a product of Americanfederalism and reflect the complexities and variabilities ofthat system. Over time, institutional long-term care for frailelders has shifted from local government funding and administrationto state-level oversight and support to a shared federal-stateconcern. The unsystematic American approach produces haphazardresults in terms of quality, equity, and efficiency. The grayingof the American population will increase the demand for long-termcare, resulting in pressure for a more coherent policy response.     

城市社区老年群体就医行为影响因素分析

日益增长的老年人健康需求是老龄化带来的诸多挑战中的一个重要方面。新一轮医药卫生体制改革突出强调基本医疗服务供给和基层卫生服务体系建设,在缓解老年人健康压力方面有一定的积极作用。老年人在身体条件、经济能力、思想观念等方面的特点,使得其就医行为受到机构服务能力、距离、费用、就医过程等多方面因素影响。在新医改背景下,需要结合这些影响因素继续完善基层医疗服务体系,以更好地满足老年群体健康需求。     

北京市城镇医药卫生体制改革研究报告

现行医药卫生体制存在卫生资源不合理,医疗费用增长过快,公立医疗机构缺乏活力,卫生资源利用效率不高,药品监管工作亟待加强等问题,针对以上问题,本提出了我市城镇医药卫生体制改革的主要内容与原则建议。     

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.     

Child Support and the Affordable Care Act's Medicaid Expansions

A quickly developing literature has shown that the Affordable Care Act's (ACA) Medicaid expansions have improved health insurance coverage, health, and financial well‐being among low‐income adults without dependent children. This population includes noncustodial parents. With substantial overlap in the population that is typically obligated to pay child support and the population that has strongly benefited from the expansions, there may be potential implications for child support enforcement. In this paper, I examine the effect of public health insurance eligibility to low‐income adults on child support outcomes. I find that the ACA Medicaid expansions increased child support distributed to custodial families as arrears by 8.5 percent. Evidence also suggests current support distributions increased by about 2 percent. There were no significant effects on paying toward a child support order. Among unmarried mothers, the likelihood of child support receipt increased by 8 percent. These results imply that access to public health insurance can increase the ability of noncustodial parents to pay child support.     

'Designing Better Health Care in the South': A Case Study of Unsuccessful Transformational Change in Public Sector Health Service Reform

This article presents a case study of a project known as 'Designing Better Health Care in the South' that attempted to transform four separately incorporated health services in southern Adelaide into a single regional health service. The project's efforts are examined using Kotter's (1996) model of the preconditions for transformational change in organisations and the areas in which it met or failed to meet these preconditions are analysed, using results from an evaluation that was commenced during the course of the attempted reform. The article provides valuable insights into an attempted major change by four public sector health organisations and the facilitators and barriers to such change. It also examines the way in which forces beyond the control of individual public sector agencies can significantly impact on attempts to implement organisational change in response to an identified need. This case study offers a rare glimpse into the micro detail of health care reform processes that are so widespread in contemporary health services but which are rarely systematically evaluated.     

State Medicaid Budgeting in Hard Times: Implications for Long-Term Care

This qualitative analysis compares the annual Medicaid budgeting processes in Utah and Illinois from the late 1970s until 1985, explaining why Utah cut the proportion spent on nursing homes and Illinois did not. It posits rational, organizational, and political process interpretations of each state's choices. The states implemented Medicaid rationing (through preadmission screening, rate freezes and adjustments, and expansion of alternatives) in significantly different ways. Utah reduced utilization of nursing homes while Illinois contained rates. Such diverse policy choices have aggravated disparities among the states in access to and quality of long-term care. Rational planning for our aging society will have to overcome these growing disparities among state policies.     

Nonincremental Policy Change: Lessons from Michigan's Medicaid Managed Care Initiative

Studies of policy implementation have focused primarily on incremental policy change, yet policy change is sometimes implemented quickly and comprehensively. Such is the case with Michigan's recent implementation of a statewide Medicaid managed care initiative. This article analyzes Michigan's quick implementation and highlights the importance of political support, organizational change, and a supportive policy and administrative environment in affecting successful implementation. It also notes the price paid for quick implementation—namely, stakeholder dissatisfaction, mistakes, and lack of public involvement.     

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.