Privatizing Public Nursing Homes: Examining the Effects on Quality and Access

This study examines the effects of local government divestment on quality and access to care for Medicaid recipients in privatized nursing homes. The central hypotheses are concerned with the impact of new ownership on both aspects of organizational performance. The analysis indicates that privatization of nursing homes involves a complex set of trade-offs. Changing organizational ownership to for-profit increases the number of regulatory violations, decreases residents' quality of life, but does not influence Medicaid admissions. While no decline in quality is found among divested nonprofit facilities, access to care declines in the comparison groups of nonprofit homes. The author concludes that as counties minimize their roles as service producers, federal, state and local governments should enhance their regulatory capacity by improving quality assurance mechanisms and providing adequate reimbursement for low-income clients.     

Welcome Mats and On‐Ramps for Older Adults: The Impact of the Affordable Care Act's Medicaid Expansions on Dual Enrollment in Medicare and Medicaid

For many low‐income Medicare beneficiaries, Medicaid provides important supplemental insurance that covers out‐of‐pocket costs and additional benefits. We examine whether Medicaid participation by low‐income adults age 65 and up increased as a result of Medicaid expansions to working‐age adults under the Affordable Care Act (ACA). Previous literature documents so‐called “welcome mat” effects in other populations but has not explicitly studied older persons dually eligible for Medicare and Medicaid. We extend this literature by estimating models of Medicaid participation among persons age 65 and up using American Community Survey data from 2010 to 2017 and state variation in ACA Medicaid expansions. We find that Medicaid expansions to working‐age adults increased Medicaid participation among low‐income older adults by 1.8 percentage points (4.4 percent). We also find evidence of an “on‐ramp” effect; that is, low‐income Medicare beneficiaries residing in expansion states who were young enough to gain coverage under the 2014 ACA Medicaid expansions before aging into Medicare were 4 percentage points (9.5 percent) more likely to have dual Medicaid coverage relative to similar individuals who either turned 65 before the 2014 expansions or resided in non‐expansion states. This on‐ramp effect is an important mechanism behind welcome mat effects among some older adults.     

Medicaid participation among the eligible elderly

This study uses data from the Survey of Income and Program Participation to address three issues: (1) what were the 1987 rates of Medicaid participation and private insurance coverage among elderly predicted to be categorically eligible and medically needy?; (2) how did these rates change between 1987 and 1992?; and (3) which factors influence insurance choices among persons who are categorically eligible for Medicaid? The 1987 Medicaid participation rates were 64 percent for the categorically eligible, but only 11 percent among the medically needy. Participation among the categorically eligible declined to 59 percent by 1992, but the difference was insignificant. In both years, about 23 percent of all categorically eligible persons had private insurance, but among those who do not participate in Medicaid, the rate rises to 48 percent.     

Turning Point Analysis: Using Survey Research to Call Changes in Consumer Behavior and Predict Sales Taxes

Forecasters often disagree on revenue predictions because of differing techniques. Some states, such as Utah, have turned to the use of survey research methods to avoid this dilemma. This article reviews many of the national forecasting models examining consumer sentiment currently in use. And it compares the Utah experience with surveys used in other states.     

Desire for Smart Growth: A Survey of Residential Preferences in the Salt Lake Region of Utah

As an alternative to sprawling development, smart growth combines proximity to work, proximity to shopping and other destinations, neighborhood housing mix, shared and paid parking, complete street designs, and proximity to public transit. This article uses a stated-choice experiment to determine residents' attitudes toward these various aspects of smart growth in the Salt Lake region of Utah. Utah is a conservative state, where attitudes toward auto-oriented suburbia may be more positive than in other parts of the United States. So, one might wonder whether changing national attitudes toward smart growth, documented in several surveys, apply to residents of the Salt Lake region. In this stated-choice experiment, respondents were asked to choose between pairs of housing scenarios with different attributes and different prices. Mixed logit (random parameters logit) was used to relate individuals' choices to attributes, prices, and sociodemographic characteristics of respondents. The results show that, generally, respondents have positive attitudes toward most aspects of smart growth but still express preferences for single-family neighborhoods with free parking in their own driveways or garages. Different life cycle cohorts have different preferences. Proximity to work is more important for childless young adults. Young families with children place higher value on living in a neighborhood with only single-family homes and transit access. Retired empty nesters favor a mix of housing types over single-family housing on one-acre-plus lots. The results suggest that while residents of the Salt Lake region like suburban neighborhoods with primarily single-family houses, they would also like to have improved accessibility to amenities in the suburbs.     

Public Health Insurance and Medical Spending: The Incidence of the ACA Medicaid Expansion

This paper examines the incidence of the cost burden associated with expanding public health insurance to low-income adults in the context of the Affordable Care Act. Using data from the Medical Expenditures Panel Survey (MEPS), I exploit exogenous variation in Medicaid eligibility rules across states, income groups and time. I find that public insurance eligibility reduced mean out-of-pocket spending by 19.6 percent among targeted households, but it did not causally increase total expenditures among beneficiaries. Rather, Medicaid expansion shifted the burden of payment from eligible households and private insurance (21.5 percent reduction) to taxpayers in the form of public insurance (46.6 percent increase). The efficiency of these public funds can be summarized by a mean Marginal Value of Public Funds of 0.70 in the full sample, 0.99 among households with at least one pre-existing condition, and 1.26 in states with an above-median number of public hospitals.     

The Effect of the Affordable Care Act Medicaid Expansion on Migration

The expansion of Medicaid to low‐income nondisabled adults is a key component of the Affordable Care Act's strategy to increase health insurance coverage, but many states have chosen not to take up the expansion. As a result, for many low‐income adults, there has been stark variation across states in access to Medicaid since the expansions took effect in 2014. This study investigates whether individuals migrate in order to gain access to these benefits. Using an empirical model in the spirit of a difference‐in‐differences, this study finds that migration from non‐expansion states to expansion states did not increase in 2014 relative to migration in the reverse direction. The estimates are sufficiently precise to rule out a migration effect that would meaningfully affect the number of enrollees in expansion states, which suggests that Medicaid expansion decisions do not impose a meaningful fiscal externality on other states.     

Access to Healthcare and Criminal Behavior: Evidence from the ACA Medicaid Expansions

I investigate the causal relationship between access to healthcare and crime following state decisions to expand Medicaid coverage after the Affordable Care Act. I combine state-level crime data from the Federal Bureau of Investigation Uniform Crime Reports for the years 2009 through 2018 with variation in insurance eligibility generated by the Medicaid expansion. Using a difference-in-differences design, my findings indicate that states that expanded Medicaid have experienced a 5.3 percent reduction in annual reported violent crime rates relative to nonexpansion states. This effect is explained by decreases in aggravated assaults and corresponds to 17 fewer incidents per 100,000 people. The estimated decrease in reported crime amounts to an annual cost savings of approximately $4 billion.     

Does the public sector outperform the nonprofit and for‐profit sectors? Evidence from a national panel study on nursing home quality and access

Are public and private organizations fundamentally different? This question has been among the most enduring inquiries in public administration. Our study explores the impact of organizational ownership on two complementary aspects of performance: service quality and access to services for impoverished clients. Derived from public management research on performance determinants and nursing home care literature, our hypotheses stipulate that public, nonprofit, and forprofit nursing homes use different approaches to balance the strategic tradeoff between two aspects of performance. Panel data on 14,423 facilities were analyzed to compare measures of quality and access across three sectors using different estimation methods. Findings indicate that ownership status is associated with critical differences in both quality and access. Public and nonprofit organizations are similar in terms of quality, and both perform significantly better than their forprofit counterparts. When compared to nonprofit and, in some cases, for‐profit facilities, public nursing homes have a significantly higher share of Medicaid recipients. The paper proposes strategies to address the identified long‐term care divide. © 2008 by the Association for Public Policy Analysis and Management.     

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 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.     

Informal caregiving as state Medicaid expenditure: an only slightly immodest proposal

States and Medicaid recipients would be better off if the federal Medicaid program allowed states to assign a dollar value to some unpaid care friends and family give to Medicaid recipients. The dollar value of this unpaid labor would then be counted as state spending in the calculation of federal match. The proposal, which would ease the pressure on tight state budgets, is entirely compatible with the recent federal-state compromise regarding provider taxes and donations and reinforces an important but overlooked Medicaid policy that cultivates and relies upon households to deliver care.     

Ivory Tower Meets Smoke-Filled Back Rooms of Politics: An Academic Perspective on Illinois' School Funding Debate

In anticipation of an upcoming legislative debate, in the early summer of 1996 public advocacy groups in Illinois contracted with the Institute of Government and Public Affairs of the University of Illinois to provide analysis of school funding reform proposals. The intent was to make the analysis and models widely available for use by government officials as well as concerned citizens. We prepared a report on options for Illinois to help focus the school funding discussion on the fundamental policy choices facing lawmakers. In this article, we summarize the process of and the university's contribution to the policy debate. Five illustrative alternatives to the current system are analyzed. While we think these options are of interest for their own sake, our primary goal in writing this article is to provide an example of how academic analysts can make a constructive contribution to heated political debate without advocating any particular plan.     

Has the Shift to Managed Care Reduced Medicaid Expenditures? Evidence from State and Local‐Level Mandates

From 1991 to 2009, the fraction of Medicaid recipients enrolled in HMOs and other forms of Medicaid managed care (MMC) increased from 11 percent to 71 percent. This increase was largely driven by state and local mandates that required most Medicaid recipients to enroll in an MMC plan. Theoretically, it is ambiguous whether the shift from fee‐for‐service into managed care would lead to an increase or a reduction in Medicaid spending. This paper investigates this effect using a data set on state‐ and local‐level MMC mandates and detailed data from the Centers for Medicare and Medicaid Services (CMS) on state Medicaid expenditures. The findings suggest that shifting Medicaid recipients from fee‐for‐service into MMC did not on average reduce Medicaid spending. If anything, our results suggest that the shift to MMC increased Medicaid spending and that this effect was especially present for risk‐based HMOs. However, the effects of the shift to MMC on Medicaid spending varied significantly across states as a function of the generosity of the state's baseline Medicaid provider reimbursement rates.     

Race and the Housing Cycle: Differences in Home Equity Trends Among Long-Term Homeowners

During the past decade, housing markets across the United States experienced dramatic upheaval. Housing prices rose rapidly throughout much of the country from 2000 until the start of 2007 and then fell sharply during the next 2 years. Many households lost substantial amounts of equity during this downturn; in aggregate, U.S. homeowners lost $7 trillion in equity from 2006 to 2009. Aggregate home equity holdings had fallen back to 2000 levels by early 2009. Whereas this intense volatility has been well documented, there remain unanswered questions about the variation in experiences across racial groups, particularly among those who purchased their homes before the boom and kept them through the collapse of the market. Did this housing market upheaval widen the already large racial and ethnic gaps in housing wealth? Using the American Housing Survey, we analyze differences in the changes in home equity experienced by homeowners of different races and ethnicities between 2003 and 2009. We focus on homeowners who remained in their homes over this period, and find that blacks and Hispanics gained less home equity than whites and were more likely to end the period underwater. Black–white gaps were driven in part by racial disparities in income and education and differences in types of homes purchased. Latino–white disparities were most dramatic during the market’s bust.     

The Federal Role in State Fiscal Stress

This article examines the extent to which the federal government'spolicies were responsible for the fiscal stress experiencedby most state governments in the early 1990s. Federal policieshave contributed considerably to recent state fiscal stress,particularly through the Medicaid program—the fastestgrowing part of state budgets—and the recession, whichdepressed revenue and increased welfare and Medicaid spending.Federal aid reductions have not been an important source ofrecent state fiscal stress. The real value of per capita federalaid other than for welfare programs fell considerably in the1980s, but the reductions were much greater for local governmentsthan for states. The largest reductions were in the early 1980s.Federal policies have affected state finances in several otherways—through tax policy, unfunded mandates, and the federalfailure to cope effectively with problems like health and poverty.Federal court rulings have also caused budget problems (as havestate court decisions). In some respects, state fiscal problemsare not a federal responsibility. Rising school enrollments,new corrections policies, and inelastic tax systems have createdfiscal stress for many states. Excessive state spending in the1980s has contributed to recent fiscal problems in some states,but not generally.     

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.     

The Effect of HAVA on Late-to-Innovate States: External Influence on Election Reform in Arizona and Illinois

As election reform diffused across the American states, therewas considerable variation in the states' willingness to innovate,their timing in doing so, and the influence of the federal HelpAmerica Vote Act (HAVA). Through the lens of the policy-diffusionliterature, this article examines the reform processes in Arizonaand Illinois, two representatives of the handful of states thatwere late in innovating, in order to test for effects of HAVAon state decision making. These "late-to-innovate" states wereunique compared with the preponderance of other states thatinnovated earlier. Typical internal variables explained whyArizona and Illinois fell into gridlock over election reforminitially, but we must turn to other (external) explanationsto understand the ultimate decisions to innovate. Also, althoughthey are similar in being late to innovate, these two statesdisplay interesting differences as well.     

The Influence of Federal Mandates on State Medicaid and AFDC Decision-Making

This article focuses on the influence of federal Medicaid mandateson state AFDC and Medicaid policy decision-making. The resultsconfirm certain concerns about federal mandates: the benefitsof federal Medicaid mandates (eligibility expansions to pregnantwomen and infants) appear to be offset by state reductions inAFDC and other Medicaid policy areas. In particular, federalMedicaid mandates had a negative effect on AFDC and MedicallyNeedy financial eligibility levels and Medicaid optional benefitcoverage—areas where states maintained discretionary power.A political-economic theory is used to test the impact of federalMedicaid mandates where a different political process is postulatedfor each policy dimension. The model is estimated using paneldata and a heteroskedastic, timewise autoregressive model.     

Interstate Spillovers,Fiscal Decentralization,and Public Spending on Medicaid Home‐ and Community‐Based Services

This article examines the interstate spillover effect of Medicaid expenditures for home‐ and community‐based services (HCBS) and tests the relationship between fiscal decentralization and public spending. Based on the theory of interstate strategic interaction, an empirical model is specified that explicitly accounts for interdependence in states’ spending decisions. The model is estimated by applying spatial econometric methods to panel data for the 50 U.S. states for 2000–2010. Findings show a positive interdependence in state HCBS expenditures that is contingent on similarity in citizen ideology between states. Fiscal decentralization, measured by transfer dependence and revenue autonomy, is positively related to Medicaid HCBS spending.