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.     

Learning from the States? Federalism and National Health Policy

In its 1993 report, the Winter Commission gave direction to the federal government in the area of health policy and Medicaid: lead, follow, or get out of the way. This article examines how the federal government responded to that advice, specifically asking what has happened in the allocation of responsibility in health policies between 1993 and 2006. In short, unlike the suggestion that there be a better‐defined direction in federal–state policy assignments in health, the ensuing years have resulted in more of the same. The authors examine what has happened, particularly focusing on vertical diffusion—where the states have acted first—and on the role of policy learning in federal decision making. They find little recognition of policy learning in recent federal health laws—even in areas in which state experience was extensive. The federal government is leading in some health policies—but it is leading without learning.     

Does the Federal Government Learn from the States? Medicaid and the Limits of Expertise in the Intergovernmental Lobby

State programmatic expertise is an important asset to federalsystems, but this expertise is not always informative to federaldecision-makers. I argue the degree to which state expertiseis informative to federal decision-makers depends on how wellthe policy interests of state and federal levels are aligned.I illustrate variation in these conditions using case studiesof congressional politics over the Medicaid program. I thenapply a statistical test, which demonstrates that states’programmatic expertise regarding Medicaid is less persuasiveto congressional committee members compared to other witnesseswho are equally knowledgeable. The results suggest a "failureof federalism," where the public good potential of state programmaticexpertise often is not realized in the federal system.     

Interstate Competition and Welfare Policy

In 1996, the federal government terminated the Aid to Familieswith Dependent Children (AFDC) program and replaced it withthe Temporary Assistance for Needy Families program (TANF).Many powers once held by the federal government are now beingused by state governments. Will welfare assistance be redesignedand expanded or will states "race to the bottom?" This issueis investigated by examining state welfare policy choices duringthe latter years of AFDC(1976–1994). Because each stateunder AFDC had the authority to set the level of its welfareguarantee for families that had no income, it is possible toestimate the effects of interstate competition on AFDC guaranteelevels. By estimating a spatial autocorrelation coefficientwhile controlling for theoretically relevant variables and statefixed effects, this study finds evidence that states are sensitiveto the welfare policies of their competitors.     

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.     

A Reevaluation of the Effects of State and ACA Dependent Coverage Mandates on Health Insurance Coverage

We study state and federal health insurance coverage mandates for young adults. Despite consistent findings that the Affordable Care Act's (ACA) federal mandate was effective, research has disagreed on whether preexisting, state-level mandates were successful in increasing coverage. We reconsider the issue with a new analytical perspective and newly available accurate data on state mandates. We show that the impact of the state mandates was substantive and concentrated among young adults between ages 19 and 23. Our estimates indicate that dependent coverage rose by 3.9 percentage points and overall coverage rose by 3.3 percentage points. Crowd-out of coverage through young adults’ own jobs was negligible. For those above 23, we find little evidence of changes in coverage. We incorporate these insights into analysis of the ACA's mandate, showing its effects were focused among those who were not eligible for state mandates, or were eligible but older than 23. Our results suggest that eligibility restrictions played important roles in limiting the scope of the state mandates, but they can be practical and effective tools for policymakers looking to ensure or expand coverage for young adults in the face of uncertainty about the ACA.     

Block Grants: A Perennial, But Unstable, Tool of Government

During 1995 and 1996, the Congress and the president gave considerableattention to block granting over $200 billion in federal intergovernmentalgrant programs, ranging from large entitlement programs to smallerprograms in housing, vocational education, and law enforcement.In the end, the record of successes was modest—highlightedby welfare-reform legislation that, in some respects, resembleda block grant and in others did not. The contrast between processand outcomes in this most recent block-grant cycle reinforcesthe point that block-grant prospects depend on fundamental fiscal,political, and programmatic forces that are separate from federalismconsiderations. The states' maturation as leaders in many domesticpolicy areas strengthens the performance rationale for blockgrants. The federal fiscal crisis will continue to stimulateinterest in block grants among fedeal as well as state policymakers.The proposals offering the greatest fiscal advantage (i.e.,Medicaid and AFDC) may not be those with the strongest performancerationale. Although recent congressional developments suggeststronger support for states, nationalizing forces remain embeddedin domestic policymaking. Thus, substantial questions remain,posing obstacles to a fundamental and sustained role for blockgrants in the federal system.     

Does state AFDC generosity affect child SSI participation?

This article examines the extent of interactions or spillovers between the Supplemental Security Income (SSI) and Aid to Families with Dependent Children (AFDC) programs for children. In the early 1990s, the Social Security Administration substantially relaxed child eligibility criteria for SSI benefits. Since the changes, the number of U.S. children receiving cash and medical benefits through SSI tripled to nearly 1 million. The article describes a family's decision to participate in SSI and/or AFDC, and uses state‐level data for three years before, and three years after, the Zebley decision to estimate the effect of state program generosity on child program participation. The expansions in child SSI eligibility increased child SSI participation and contributed to increased total program participation by children in the early 1990s. Child SSI participation increased more in states with lower AFDC payments and higher state SSI supplementation payments. These results suggest that families use SSI and AFDC as substitutes. At least 32 percent of the Zebley increase in SSI is likely attributable to the SSI–AFDC benefit gap for the median AFDC benefit state. © 2000 by the Association for Public Policy and Management.     

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.     

State TANF Spending: Predictors of State Tax Effort to Support Welfare Reform

State spending on Temporary Assistance to Needy Families (TANF) greatly varies. Combined federal and state spending by the states per TANF family or recipient reflects the historic level of state generosity for Aid to Families with Dependent Children (AFDC), the failure of the federal government to set any minimum spending standard for the states, and the failure of the federal government to adjust federal grants for huge changes in state TANF caseloads. Our multivariate analysis shows that state spending for TANF is greatly influenced by the percentage of the state population that is black, the percentage of the state population that is on TANF (especially if a significant percentage of the rolls consist of black recipients), and the economic conditions within the state. Some states spend as much as their economies will allow, while other states spend far below capacity. Despite the very different goals of TANF, state spending is still heavily influenced by their historic approach to AFDC.     

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.     

Mandates and Management Challenges in the Trenches: An Intergovernmental Perspective on Homeland Security

Scholars and practitioners agree that homeland security policy implementation is contingent on a strong system of intergovernmental relations. The responsibilities associated with the homeland security mission, often mandated, cut across federal, state, and local boundaries. Local-level stakeholders are especially important players in the implementation process. This article presents a local perspective on the way intergovernmental relations have changed—and the reasons for those changes—since 9/11. Results of a survey of county and city officials in Florida provide evidence that intergovernmental cooperation has improved as a result of federal and state mandates. These results are refined by an analysis of the effects of specific local characteristics and the quality and quantity of vertical and horizontal networks on intergovernmental cooperation and local preparedness. Homeland security appears to be a policy area in which mandated cooperation and coordination—in a time and place of urgency—have actually strengthened the intergovernmental system.     

A Song of Policy Incongruence: The Missing Choir of Consumer Preferences in GMO‐Labeling Policy Outcomes

This article focuses on the degree of policy congruence, and by extension policy responsiveness, of U.S. federal‐ and state‐level GMO labeling laws from 2011–2016. Utilizing consumer survey data, evidence overwhelmingly demonstrates consumers prefer clear text‐based indication if food products contain genetically modified ingredients. However, the federal law adopted in 2016 mandates GMO labeling but with exceptions permitted to clear on‐package text labeling. The results of this study demonstrate that consumer preferences were not adequately represented at the federal level and were misaligned with state policy activities as captured in the aggregate outcome. State legislatures were actively proposing mandatory legislation with only a few cases of success, which did not adequately represent the wishes of the people. Given the misalignment and overall policy incongruence, the consequences of pending federal law are discussed in light of why the voices of the consumer choir were not heard by lawmakers.     

The TANF/SSI connection

Interactions and overlap of social assistance programs across clients interest policymakers because such interactions affect both the clients' well-being and the programs' efficiency. This article investigates the connections between Supplemental Security Income (SSI) and Temporary Assistance for Needy Families (TANF) and TANF's predecessor, the Aid to Families with Dependent Children (AFDC) program. Connections between receipt of TANF and SSI are widely discussed in both disability policy and poverty research literatures because many families receiving TANF report disabilities. For both states and the individuals involved, it is generally financially advantageous for adults and children with disabilities to transfer from TANF to SSI. States gain because the federal government pays for the SSI benefit, and states can then use the TANF savings for other purposes. The families gain because the SSI benefits they acquire are greater than the TANF benefits they lose. The payoff to states from transferring welfare recipients to SSI was substantially increased when Congress replaced AFDC with TANF in 1996. States retained less than half of any savings achieved through such transfers under AFDC, but they retain all of the savings under TANF. Also, the work participation requirements under TANF have obligated states to address the work support needs of adults with disabilities who remain in TANF, and states can avoid these costs if adults have disabilities that satisfy SSI eligibility requirements. The incentive for TANF recipients to apply for SSI has increased over time as inflation has caused real TANF benefits to fall relative to payments received by SSI recipients. Trends in the financial incentives for transfer to SSI have not been studied in detail, and reliable general data on the extent of the interaction between TANF and SSI are scarce. In addition, some estimates of the prevalence of TANF receipt among SSI awardees are flawed because they fail to include adults receiving benefits in TANF-related Separate State Programs (SSPs). SSPs are assistance programs that are administered by TANF agencies but are paid for wholly from state funds. When the programs are conducted in a manner consistent with federal regulations, the money states spend on SSPs counts toward federal maintenance-of-effort (MOE) requirements, under which states must sustain a certain level of contribution to the costs of TANF and approved related activities. SSPs are used for a variety of purposes, including support of families who are in the process of applying for SSI. Until very recently, families receiving cash benefits through SSPs were not subject to TANF's work participation requirements. This article contributes to analysis of the interaction between TANF and SSI by evaluating the financial consequences of TANF-to-SSI transfer and developing new estimates of both the prevalence of receipt of SSI benefits among families receiving cash assistance from TANF and the proportion of new SSI awards that go to adults and children residing in families receiving TANF or TANF-related benefits in SSPs. Using data from the Urban Institute's Welfare Rules Database, we find that by 2003 an SSI award for a child in a three-person family dependent on TANF increased family income by 103.5 percent on average across states; an award to the adult in such a family increased income by 115.4 percent. The gain from both child and adult transfers increased by about 6 percent between 1996 (the eve of the welfare reform that produced TANF) and 2003. Using data from the Department of Health and Human Services' TANF/SSP Recipient Family Characteristics Survey, we estimate that 16 percent of families receiving TANF/SSP support in federal fiscal year 2003 included an adult or child SSI recipient. This proportion has increased slightly since fiscal year 2000. The Social Security Administration's current procedures for tabulating characteristics of new SSI awardees do not recognize SSP receipt as TANF We use differences in reported TANF-to-SSI flows between states with and without Separate State Programs to estimate the understatement of the prevalence of TANF-related SSI awards in states with SSPs. The results indicate that the absolute number of awards to AFDC (and subsequently) TANF/SSP recipients has declined by 42 percent for children and 25 percent for adults since the early 1990s. This result is a product of the decline in welfare caseloads. However, the monthly incidence of such awards has gone up-from less than 1 per 1,000 child recipients in calendar years 1991-1993 to 1.3 per 1,000 in 2001-2003 and, for adult recipients, from 1.6 per 1,000 in 1991-1993 to 4 per 1,000 in 2001-2003. From these results we conclude that a significant proportion of each year's SSI awards to disabled nonelderly people go to TANF/SSP recipients, and many families that receive TANF/SSP support include adults, children, or both who receive SSI. Given the Social Security Administration's efforts to improve eligibility assessment for applicants, to ensure timely access to SSI benefits for those who qualify, and to improve prospects for eventual employment of the disabled, there is definitely a basis for working with TANF authorities both nationally and locally on service coordination and on smoothing the process of SSI eligibility assessment. The Deficit Reduction Act of 2005 reauthorized TANF through fiscal year 2010, but with some rules changes that are important in light of the analysis presented in this article. The new law substantially increases effective federal requirements for work participation by adult TANF recipients and mandates that adults in Separate State Programs be included in participation requirements beginning in fiscal year 2007. Thus SSPs will no longer provide a means for exempting from work requirements families that are in the process of applying for SSI, and the increased emphasis on work participation could result in more SSI applications from adult TANF recipients.     

The devil may be in the details: how the characteristics of SCHIP programs affect take-up.

In this paper, we explore whether the specific design of a state's program has contributed to its success in meeting two objectives of the Children's Health Insurance Program (SCHIP): increasing the health insurance coverage of children in lower income families and doing so with a minimum reduction in their private health insurance coverage (crowd-out). In our analysis, we use two years of Current Population Survey data, 2000 and 2001, matched with detailed data on state programs. We focus on two populations: the eligible population of children, broadly defined--those living in families with incomes below 300 percent of the federal poverty line (FPL)--and a narrower group of children, those who we estimate are eligible for Medicaid or SCHIP. Unique state program characteristics in the analysis include whether the state plan covers families; whether the state uses presumptive eligibility; the number of months without private coverage that are required for eligibility; whether there is an asset test; whether a face-to-face interview is required; and specific outreach activities. Our results provide evidence that state program characteristics are significant determinants of program success.     

The State of American Federalism, 1993-1994

National political energies in 1993–1994 were focusedon major initiatives promised by the Clinton administrationduring the 1992 presidential campaign, especially health-carereform and crime. From the perspective of the states, federalgovernment action in these (and other) policy areas raised seriousquestions about preemption and mandates. The administration'sofficial pronouncements on federalism have suggested a strategyof decongestion and decentralization. Thus far, its actionshave fallen short of empowerment, taking instead the path ofregulatory waivers. Frustrated with the federal government,states and localities continued to engage in policy experimentation.     

State Fiscal Strategies for the 1990s: Balancing Budgets in a Recession

The fiscal crunch facing many states in FY 1991 has its rootsin the recession, federal mandates, election-year politics,and rapid growth in spending for Medicaid and corrections. Southernand midwestern states that made drastic cuts in response tothe 1981–1982 recession have fared relatively well, butstates in the Northeast have faced tax increases, layoffs, cutsin services, and prolonged conflict over state budgets. Althoughthe tax revolt has not led to appreciably lower taxes, it hasmade raising taxes more difficult, and has heralded a shiftto "boutique government," which may create further fiscal problemsin the long run. State tax increases and spending cutbacks mayalso delay recovery from the recession.     

Intergovernmental Management: Federal Changes, State Responses, and New State Initiatives

This article surveys state responses and new state initiativesin 1983 to three sets of successive federal changes in domesticpolicy. Collectively referred to as the New Federalism, thesechanges include the block grants and accompanying regulatoryreforms of 1981, the changes in Medicaid reimbursement policyof 1982, and the job training and development programs of late1982 and early 1983. Following a brief overview of these changesin intergovernmental management perspective, state responsesin 1983 are examined in three areas—policy development,policy and program management, and service delivery management.     

SSI eligibility and participation among the oldest old: evidence from the AHEAD

The proportion of elderly SSI recipients aged 70 or older has been growing in recent years, perhaps because of rising life expectancies overall and a higher incidence of poverty among the oldest old. In 1999, 84 percent of all elderly SSI recipients were 70 or older. This article examines Supplemental Security Income (SSI) eligibility and participation among the oldest old. The analysis was based on 1993 data from the Study of Assets and Health Dynamics Among the Oldest Old that were used to build a detailed SSI eligibility model to identify individuals who meet the federal criteria for SSI income and resource eligibility. The participation rate among those eligible for federal SSI benefits is 53.9 percent, which is generally consistent with the findings of other studies. Furthermore, eligible participants would receive a significantly higher federal SSI benefit than eligible nonparticipants. Correspondingly, eligible participants have significantly lower incomes and assets than eligible nonparticipants. An econometric model is used to estimate the influence of various demographic, financial, and health care use characteristics on the probability of SSI participation among eligible individuals and couples. The model corrects for measurement error in calculated benefits and for misclassifying someone as ineligible. The empirical results show that the effect of higher SSI benefits on the probability of participation is substantial--a $100 increase in benefits would increase the probability of participating for an average eligible unit by 15 percentage points. Many of the demographic, financial, and health care use variables also are important predictors of SSI participation among the oldest old. The eligibility and participation models are also used to simulate the effect of increasing the SSI unearned income disregard from $20 to $125. Those made eligible by this policy change would receive a very low federal SSI benefit on average, suggesting that they are on the margin of eligibility under the original program rules. The simulated participation rate is 48.8 percent--5 percentage points lower than under the original program rules--reflecting the low benefit that new eligibles would receive. Only 36 percent of those made eligible by the new program rules are predicted to participate. These SSI eligibility and participation models are potentially useful tools for policy analysis. It is fairly straightforward to use these models to change a feature of SSI eligibility, reestimate the group of eligible individuals and couples, and predict participation among those who are eligible under the simulated program rules. New eligibles can be compared with those eligible under original program rules. New participants can be compared with old participants. Although these models focus only on individuals aged 70 or older, this type of analysis can be helpful in estimating the potential distributional effects of proposed SSI policy changes.