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.     

The State of American Federalism, 1996-1997

Federalism enjoyed political and popular salience during theperiod 1996–1997 as the so-called "Devolution Revolution"began to be implemented and analyzed in the United States. Whilethere were a few examples of important Revolutionary efforts,the federal government continued to hold much of the power andsignificance it has achieved over the past sixty years. Evenin the area of welfare policy, where in 1996 there were historicreforms enacted to end the federal entitlement, the federalgovernment maintained a significant presence that made the ideaof devolution of welfare policy responsibility some what questionable.Nevertheless, states continued to lead in policy innovationin areas ranging from education to health, and the U.S. SupremeCourt continued to question the limits of federal power. Thepast year illustrated, once again, the complexity of our federalsystem and how difficult it is to reform federalism—particularlywhen it involves a shift in power and creates the perceptionof winners and losers.     

Two Decades of Change: A Ranking of Key Issues Affecting Intergovernmental Relations

This article describes the results of a 1981 survey of 1,000randomly selected scholars of American government and politicswho were asked to rank the most significant intergovernmentalevents and trends of the past twenty years. Responses were receivedfrom almost 40 percent of these scholars; no significant returnbiases were detected. These scholars ranked civil rights andvoting rights acts as the most significant events of these decades.General Revenue Sharing and the reapportionment cases were rankedsecond and third in importance. The increased flow of federaldollars to states and local governments was ranked the mostimportant trend affecting intergovernmental relations, followedby the increased public disaffection with government and thegrowing dependence of local governments on state and federalaid. The Vietnam War and the inflationary spiral it initiatedwas ranked as the most significant social event affecting thecourse of intergovernmental relations, followed closely by theenergy crisis and the beginnings of the "Great Society." Thearticle also examines the effects of party identification, age,year of degree, government experience, region, and city sizeon scholarly attitudes toward these events and trends. Whilethe overall rankings were not dramatically altered, partisanship,region, and city size all were factors found to be noticeablyrelated to scholarly rankings of these important events andtrends.     

The State of American Federalism, 1997 - 1998

Although it was a relatively quiet year for the courts and congressionalaction, 1997–1998 saw several developments that may significantlydefine federalism in the coming years. The 1998 federal budgetis projected to show a surplus, ending decades of deficit financinginWashington, D.C., but also raising questions about the budget'sfiscal impact on federalism and intergovernmental relations.Devolution took a back seat in Washington, D.C., as concernsabout managed care, education, and internet access led to proposalsfor increased federal involvement in state and local affairs.The states continued their implementation of welfare reformand launched other programs in health, environment.     

Low-level Radioactive Waste Compacts: Lessons Learned from Theory and Practice

The interstate compact as a policy tool has a long history ofuse in the United States. Yet some observers feel that interstatecompacts have never lived up to their potential. Nevertheless,in 1980, the compact was chosen as the policy instrument tosolve one of the thorniest environmental policy issues of thedecade: the siting of low-level radioactive waste (LLRW) disposalfacilities. Drawing from research on interstate compacts andon alliance theory developed in international relations, thisarticle applies five key questions to the case of LLRW: Whydo states join compacts? Which compacts will they join? Howstable are the compacts? How important are outside factors?What types of situations are compacts most suited to address?It concludes with lessons that should be useful to future policymakersabout the use of interstate compacts to solve salient, nationwidepolicy problems.     

Hard choices: targeting long-term care to the "at risk" aged

Recent expansion of Medicaid coverage to home- and community-based long-term care moves that payment program away from its traditional institutional bias. But tension over the appropriate role of home care and fears of budget-busting have caused the current administration to set goals for the states that may be impossible to achieve.     

Toward a continuum of care for the elderly: a note of caution

The search for better ways to care for the chronically ill elderly has led to "alternatives to institutional care." A study fo geriatric day care and homemaker services finds that they were used as an add-on to existing care, few patients benefited, and costs were 60-71% higher than costs of a control group. Four more studies have confirmed the lack of substitution effects. Services could be targeted on those who need them even though it is very difficult to do so, and efficacy should be demonstrated before benefits are expended to new services.     

Using home equity to finance long-term care

A majority of elderly Americans have the bulk of their assets tied up in the houses they own. Reverse mortgages could tap this home equity, providing loan disbursements without requiring older homeowners to make monthly payments on principal and interest. In this paper we analyze the potential of using home equity to finance long-term care of the elderly, including payments for home care and for long-term care insurance. We first estimate each homeowner's risk of need for care (and risk of institutionalization) and then calculate the degree to which home equity could be used to cover the costs of home care (or of insurance premiums). Special emphasis is placed on those in the highest risk group and on those with the lowest incomes, who often turn out to be the same people.