Medicaid in the 1990s: Trends, Innovations, and the Future of the "PAC-Man" of State Budgets

Rapidly escalating health-care inflation and congressionallymandated expansions have led to large increases in spendingfor Medicaid, the federal-state program of health care for thepoor. These increases came at a time when state budgets werealready under recession-induced stresses. In addition, 1991brought new pressures for Medicaid spending from the courtsand closer federal scrutiny and control over revenues used forthe program's state "match." Yet the Medicaid picture is farfrom bleak. Diversity, innovation, and an emerging stale policyrole also characterize the program in ways that epitomize thestrengths and weaknesses of the American intergovernmental system.     

When is Growth Not Growth? The Curious Case of Mental Health Budgeting in New York

This article argues that the adverse impact of Medicaid on state budgets alleged in various public debates has been overstated, in some measure because of the inaccurate and misleading manner in which Medicaid expenditures are appropriated in state budgeting systems. Data on Medicaid and mental health spending in the state of New York is used for analysis. The first section provides a Medicaid spending and budgeting background. The second section discusses Medicaid and mental health in New York. The third section describes actual budgeted spending for mental health in New York, and the final section provides a discussion and concluding comments.     

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.     

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's Role in Moves Toward Universal Health Care

This paper considers the problems currently facing the Medical Assistance (Medicaid) program in light of the major problems confronting the American health care system. Actual and proposed Medicaid reforms are reviewed, their merits noted and their shortcomings detailed. It is argued that substantial Medicaid reform can take place only in the context of radical reform of the entire U.S. health care system. Similarly, Medicaid should be incorporated into any plan aimed at providing universal health care coverage.     

Excellence at What Cost? Austerity and the Reform of the School System in England (2010–2016)

The reform of the school system, which has been conducted by the Coalition and Conservative governments since 2010, has largely been austerity‐driven. In spite of the governments’ pledge to protect their budgets, schools have been severely hit by spending cuts. The reform programme has itself been integral to the fiscal consolidation plans by promoting a more cost‐effective system of state schooling. This article discusses the relationship between austerity and reform, and looks at the consequences for the concept of public service. Some specific aspects of the new institutional framework are examined, especially the creation of an independent state sector made up of academies and free schools, which has entrenched the involvement of private sector firms in education. The overhaul of the school system, which started nearly thirty years ago, has now reached a new decisive stage. However, considering the complex relationship between multiple actors and the opposing forces at work, one cannot say with any certainty that it will cause the demise of public service state education.     

LONG TERM CARE REGULATION IN THE STATES: A SYSTEMIC PERSPECTIVE

In recent years there has been growing interest in differing state roles in the regulation of the health care industry. Most of this attention has stressed the impact of regulatory policy with only superficial attention directed towards understanding the extent to which states can be counted on to act effectively in the area of health care regulation. Using the regulation of nursing homes as a focus, this study evaluates a variety of sociocultural, political, and economic conditions for their impact on the development of various regulatory policies. The findings suggest that the development of certificate of need legislation and reimbursement controls were not related to significant changes ir, states' budgets for Medicaid services or in bed/population ratios. Instead, regulatory efforts were more closely linked to the sociopolitical environments surrounding the policy arena. While these factors provide some indication of the potential for strong state action in the regulatory arena, ultimately the use of state regulatory policies will depend quite centrally on the innovative tendencies of the state, its organizational capacity for addressing policy issues, and the nature and extent of interest group politics.     

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.     

The Impact of Welfare Reform on Medicaid

Welfare reform did not usher in comprehensive Medicaid reform,if "reform" is defined as dismantling the basic framework ordesign of the nations's health-care system for the poor. Instead,it left much of the previous Medicaid system intact. However,welfare reform has contributed to changes in the Medicaid-eligiblepopulations, greater variability and experimentation with stateMedicaid initiatives, and greater sate control over Medicaidprogram decisions. Thus, the welfare-reform movement clarifieda major trend in contemporary American politics—the increasein state discretion and flexibility in social welfare policymaking.The states are now at the center of Medicaid decisionmaking,and they are in a key position to determine the future directionof heath-care assistance for the poor in the United States.     

Sozialpolitik im Finanzföderalismus – Hartz IV als Antwort auf die Krise der Kommunalfinanzen

In the literature on welfare state reforms, continental welfare states like Germany have been considered to be resistant to reform. However, recently scholars started to argue that new reform coalitions and policy learning have led to a major restructuring of the German welfare state. In this article we introduce a third argument into the debate and claim that the recent reforms can only be understood by taking into account the specific structure of welfare state financing in Germany. Focusing on the reform of unemployment benefits we show that the crisis of the widespread cost-shifting practice between the federal budget, the social insurance and local authority budgets contributed to fiscal problems which could ultimately only be resolved by engaging in a fundamental restructuring of the financing architecture of welfare provisions for the long-term unemployed.     

In the Eye of the Storm? Societal Aging and the Future of Public‐Service Reform

One of the principal motivations for the reinvention of many central governments over the last two decades is the need to deal with chronic budget deficits. As budget surpluses reappeared at the end of the 1990s, the pressure to restructure seemed to ease in some countries. However, observers suggested the relief was only temporary, and aging populations would soon put more stress on government budgets, creating a need for further retrenchment. This article assesses the vulnerability of three central governments—the United Kingdom, Canada, and the United States—to aging-related fiscal stress. Because of institutional differences, the U.S. government is likely to be hit hardest by this demographic change. This may imply that public-sector reform will take a different path in the United States than it will in the United Kingdom or Canada.     

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.     

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.     

State health reform: Effects on labor markets and economic activity

Individual states are actively weighing health care reform proposals and their potential impacts on many levels, including states' own economies. This article considers the effects on state economies of two instruments of health reform: employer mandates and cost containment. The literature suggests that an employer mandate will reduce employees' wages in the long run. In the short run, however, to compensate for the costs associated with mandated health care insurance for their employees, firms may raise their prices to consumers, reduce the number of employees or allow a drop in profit margins. By increasing health care spending and the number of insured persons, mandates would also increase states' levels of economic activity. Though cost containment may dampen the stimulative effects of expanded coverage, resources not spent on health care as a result of effective cost containment might be redistributed to other sectors in a state's economy.     

State Social Services Contracting: Exploring the Determinants of Effective Contract Accountability

This article examines the effectiveness of contract accountability in social service contracts. The analysis is based on five case studies of Kansas contracts for selected welfare, Medicaid, and foster care and adoption services. Results indicate the state has achieved moderate to high levels of accountability effectiveness, especially in terms of specifying social service contracts and selecting appropriate accountability strategies. However, accountability is undermined by the use of risk shifting, reliance on a system of multiple competing providers, and the adoption of new information technologies. These conclusions contradict the conventional wisdom, theory, and existing research on contracting.     

State and Local Fiscal Sustainability: The Challenges

At the state and local level, fiscal sustainability is the long‐run capability of a government to consistently meet its financial responsibilities. It reflects the adequacy of available revenues to ensure the continued provision of the service and capital levels that the public demands. After examining separate revenue and expenditure trends for state and local governments, this article identifies three specific sets of pressures that affect subnational fiscal sustainability—cyclical, structural, and intergovernmental. It then presents three specific examples of these pressures: Medicaid, pensions and retiree health benefits, and infrastructure. The author asserts that without changes in the fiscal system—in both revenues and expenditures—state and local fiscal sustainability will disappear. It concludes with some potential solutions but argues that the most difficult reform is to ensure that the public understands that there is no such thing as a free lunch.     

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.     

Prospects for Low-Income Mothers' Economic Survival Under Welfare Reform

This article discusses implications of data on the income andemployment patterns of welfare recipients for the types of programmaticand financial investments that states will need to make forsuccessful welfare reform. Research by the Institute for Women'sPolicy Research found that even before welfare reform, womenworked significant amounts of time and relied heavily on familysupports to survive, when possible. High school education andjob training are important predictors of having welfare andescaping poverty, while work experience alone has relativelylittle effect on leaving welfare. States will be challengedto provide these educational services within the restrictionson job training and education under the new welfare laws. Workingwelfare recipients in the institute's sample spent more thanone third of their income on child care, which speaks to theimportance of increased child-care subsidies for helping womenescape poverty. It is important for states and communities tomonitor the implementation of supportive services, track outcomesfor women who leave welfare, and improve work environments andemployment benefits.     

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.     

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.