Law Commons^™

Affirmatively Furthering Health Equity, Mary Crossley

Articles

Pervasive health disparities in the United States undermine both public health and social cohesion. Because of the enormity of the health care sector, government action, standing alone, is limited in its power to remedy health disparities. This Article proposes a novel approach to distributing responsibility for promoting health equity broadly among public and private actors in the health care sector. Specifically, it recommends that the Department of Health and Human Services issue guidance articulating an obligation on the part of all recipients of federal health care funding to act affirmatively to advance health equity. The Fair Housing Act’s requirement that …

Prisons, Nursing Homes, And Medicaid: A Covid-19 Case Study In Health Injustice, Mary Crossley

Articles

The unevenly distributed pain and suffering from the COVID-19 pandemic present a remarkable case study. Considering why the coronavirus has devastated some groups more than others offers a concrete example of abstract concepts like “structural discrimination” and “institutional racism,” an example measured in lives lost, families shattered, and unremitting anxiety. This essay highlights the experiences of Black people and disabled people, and how societal choices have caused them to experience the brunt of the pandemic. It focuses on prisons and nursing homes—institutions that emerged as COVID-19 hotspots –and on the Medicaid program.

Black and disabled people are disproportionately represented in …

The Health Care Costs Of Financial Exploitation In Maine, Kimberly I. Snow Mhsa, Yvonne Jonk Phd, Deborah Thayer Mba, Catherine Mcguire Bs, Stuart Bratesman Mpp, Charles A. Smith Phd, Erika C. Ziller Phd

Disability & Aging

This study sought to determine the Medicare and Medicaid costs experienced by dual eligible older adults in Maine for whom Maine Adult Protective Services (APS) substantiated allegations of elder financial exploitation and to compare them to those of Maine’s general older population. The analysis is an important step forward in estimating the medical costs associated with elder abuse.

Elder financial exploitation may result in significant public burden on Medicare and Medicaid, shouldered by taxpayers. Efforts to detect, investigate, prosecute, and mitigate this abuse will benefit not only the victims, but also the financial stewardship of these public programs.

The Shadows Of Life: Medicaid's Failure Of Health Care's Moral Test, Barak D. Richman, Kushal T. Kadakia, Shivani A. Shah

Faculty Scholarship

North Carolina Medicaid covers one-fifth of the state’s population and makes up approximately one-third of the budget. Yet the state has experienced increasing costs and worsening health outcomes over the past decade, while socioeconomic disparities persist among communities. In this article, the authors explore the factors that influence these trends and provide a series of policy lessons to inform the state’s current reform efforts following the recent approval of North Carolina’s Section 1115 waiver by the Centers for Medicare and Medicaid Services. The authors used health, social, and financial data from the state Department of Health and Human Services, the …

Threats To Medicaid And Health Equity Intersections, Mary Crossley

Articles

2017 was a tumultuous year politically in the United States on many fronts, but perhaps none more so than health care. For enrollees in the Medicaid program, it was a “year of living precariously.” Long-promised Republican efforts to repeal the Affordable Care Act also took aim at Medicaid, with proposals to fundamentally restructure the program and drastically cut its federal funding. These proposals provoked pushback from multiple fronts, including formal opposition from groups representing people with disabilities and people of color and individual protesters. Opposition by these groups should not have surprised the proponents of “reforming” Medicaid. Both people of …

Effects Of The Affordable Care Act On Health Behaviors After Three Years, Charles J. Courtemanche, James Marton, Benjamin Ukert, Aaron Yelowitz, Daniela Zapata

Institute for the Study of Free Enterprise Working Papers

This paper examines the impacts of the Affordable Care Act (ACA) – which substantially increased insurance coverage through regulations, mandates, subsidies, and Medicaid expansions – on behaviors related to future health risks after three years. Using data from the Behavioral Risk Factor Surveillance System and an identification strategy that leverages variation in pre-ACA uninsured rates and state Medicaid expansion decisions, we show that the ACA increased preventive care utilization along several dimensions, but also increased risky drinking. These results are driven by the private portions of the law, as opposed to the Medicaid expansion. We also conduct subsample analyses by …

Early Effects Of The Affordable Care Act On Health Care Access, Risky Health Behaviors, And Self-Assessed Health, Charles J. Courtemanche, James Marton, Benjamin Ukert, Aaron Yelowitz, Daniela Zapata

Institute for the Study of Free Enterprise Working Papers

The goal of the Affordable Care Act (ACA) was to achieve nearly universal health insurance coverage through a combination of mandates, subsidies, marketplaces, and Medicaid expansions, most of which took effect in 2014. We use data from the Behavioral Risk Factor Surveillance System to examine the impacts of the ACA on health care access, risky health behaviors, and self-assessed health after two years. We estimate difference-in-difference-in-differences models that exploit variation in treatment intensity from state participation in the Medicaid expansion and pre-ACA uninsured rates. Results suggest that the ACA led to sizeable improvements in access to health care in both …

Covering The Care: Health Insurance Coverage In New Hampshire, Jo Porter, Lucy Hodder

Law Faculty Scholarship

the first in a series of data and policy briefs that seek to inform the current conversations about health reform happening across the state. The first brief uses data from the American Community Survey to provide information about the health insurance coverage landscape in NH.

N.C. Medicaid Reform: A Bipartisan Path Forward, Barak D. Richman, Allison Rice

Faculty Scholarship

The North Carolina Medicaid program currently constitutes 32% of the state budget and provides insurance coverage to 18% of the state’s population. At the same time, 13% of North Carolinians remain uninsured, and even among the insured, significant health disparities persist across income, geography, education, and race.

The Duke University Bass Connections Medicaid Reform project gathered to consider how North Carolina could use its limited Medicaid dollars more effectively to reduce the incidence of poor health, improve access to healthcare, and reduce budgetary pressures on the state’s taxpayers.

This report is submitted to North Carolina’s policymakers and citizens. It assesses …

Community Integration Of People With Disabilities: Can Olmstead Protect Against Retrenchment?, Mary Crossley

Articles

Since the passage of the Americans with Disabilities Act (ADA) in 1990, states have made significant progress in enabling Americans with disabilities to live in their communities, rather than institutions. That progress reflects the combined effect of the Supreme Court’s holding in Olmstead v. L.C. ex rel. Zimring, that states’ failure to provide services to disabled persons in the community may violate the ADA, and amendments to Medicaid that permit states to devote funding to home and community-based services (HCBS). This article considers whether Olmstead and its progeny could act as a check on a potential retrenchment of states’ …

Community Health Centers And Medicaid Payment Reform: Emerging Lessons From Medicaid Expansion States, Peter Shin, Jessica Sharac, Zoe Barber, Sara J. Rosenbaum

Geiger Gibson/RCHN Community Health Foundation Research Collaborative

Community health centers represent a major source of primary health care for the nation’s Medicaid beneficiaries. Because the Federally Qualified Health Center (FQHC) payment system is encounter-based, health centers and Medicaid agencies in ACA expansion states are actively pursuing payment reforms that will enable health centers to adopt strategies that can more effectively respond to the considerable and complex health and social needs of people served by health centers, and more efficiently address the surging volume of patient care. In five expansion states whose alternative payment experiments are underway, health centers and Medicaid agencies are testing payment alternatives, such as …

Reimagining The Risk Of Long-Term Care, Allison K. Hoffman

All Faculty Scholarship

U.S. law and policy on long-term care fail to address the insecurity American families face due to prolonged illness and disability — a problem that grows more serious as the population ages and rates of disability rise. This Article argues that, even worse, we have focused on only part of the problem. It illuminates two ways that prolonged disability or illness can create insecurity. The first arises from the risk of becoming disabled or sick and needing long-term care, which could be called “care-recipient” risk. The second arises out of the risk of becoming responsible for someone else’s care, which …

The Reverberating Risk Of Long-Term Care, Allison K. Hoffman

All Faculty Scholarship

The Fiftieth Anniversary of Medicare and Medicaid offers an opportunity to reflect on how American social policy has conceived of the problem of long-term care. In this essay, based on a longer forthcoming article, I argue that current policies adopt too narrow a conception of long-term care risk, by focusing on the effect of serious illness and disability on people who need care and not on the friends and family who often provide it. I propose a more complete view of long-term care risk that acknowledges how illness and disability reverberates through communities, posing insecurity for people beyond those in …

Financial Security Scorecard: A State-By-State Analysis Of Economic Pressures Facing Future Retirees, Christian Weller, Nari Rhee, Carolyn Arcand

Public Policy and Public Affairs Faculty Publication Series

As Americans increasingly worry about their retirement prospects, states play an important and growing role in retirement security policy. States already manage long-term care programs for the elderly through Medicaid. Concerned about the impact of future elder poverty on state and local budgets and their local economies, a number of states are exploring the creation of low-cost and low-risk retirement savings plans for private sector workers who lack access to pensions or 401(k)s on the job. Some states have developed programs to help older workers find work.

This report presents the Financial Security Scorecard, designed to inform state-level stakeholders and …

Cultural Collisions And The Limits Of The Affordable Care Act, Jasmine E. Harris

All Faculty Scholarship

National Federation of Independent Business v. Sebelius (“NFIB”) settled the central constitutional questions impeding the rollout of the Patient Protection and Affordable Care Act (“ACA”): whether the federal government’s “individual mandate” to purchase or hold health insurance and the federal government’s authority to retract existing federal dollars if states fail to expand Medicaid eligibility violate the Constitution. However, a number of residual questions persist in its wake. While most of the focus this year has been on related constitutional issues — such as religious exemptions from offering contraceptive coverage to employees — NFIB also clears the path for a discussion …

Giving Meaning To 'Meaningful Access' In Medicaid Managed Care, Mary Crossley

Articles

As states seek to shift Medicaid recipients with disabilities out of traditional fee-for-service settings and into managed care plans, vexing questions arise about the impact on access to needed care and providers for beneficiaries with medically complex needs. With many states expanding their Medicaid program as part of health care reform and cost-containment pressures continuing to mount, this movement will likely accelerate over the next several years. This Article examines the possibility that disability discrimination law might provide a mechanism for prodding states in the planning stage to anticipate and plan for likely access issues, as well as for challenging …

Implications Of Rhode Island’S Global Consumer Choice Compact Medicaid Waiver For Block Granting Medicaid And Other Retrenchment, Edward Alan Miller, Divya Samuel, Susan Allen, Amal Trivedi, Vincent Mor

Gerontology Institute Publications

On January 16, 2009, the Federal government approved Rhode Island’s application for a Global Consumer Choice Compact Medicaid Waiver whereby the state became the first granted permission to operate its entire Medicaid program under the state plan and a single 1115 “research and demonstration” waiver. The Global Waiver has been implemented in the context of Republican proposals to turn Medicaid into a block grant which would give states substantially more flexibility administering the program in exchange for receiving an upfront allotment from the Federal government. Proponents have held up the Global Waiver as a successful example of what might be …

Implications Of Rhode Island’S Global Consumer Choice Compact Medicaid Waiver For Rebalancing Long-Term Care Under The Affordable Care Act, Edward Alan Miller, Divya Samuel, Susan Allen, Amal Trivedi, Vincent Mor

Gerontology Institute Publications

Federal approval of Rhode Island’s Global Consumer Choice Compact Global Waiver in 2009 provided Rhode Island with greater flexibility to modify its Medicaid program. Because 96% of long-term care expenditures in Rhode Island were directed toward institutional settings, a primary goal was to facilitate the state’s efforts to shift the locus of long-term care to non-institutional settings. This study draws lessons from Rhode Island’s experience with the Global Waiver for the long-term care rebalancing provisions of the Patient Protection and Affordable Care Act of 2010. Data derive from 325 archival sources and 26 semi-structured interviews. Results suggest that prospectively documenting …

Implications Of Rhode Island’S Global Consumer Choice Compact Medicaid Waiver For Designing And Implementing State Health Reform, Edward Alan Miller, Divya Samuel, Susan Allen, Amal Trivedi, Vincent Mor

Gerontology Institute Publications

Provisions in the Medicaid statute permit states to apply for waivers from traditional program requirements. On January 16, 2009, the federal government approved Rhode Island's Global Consumer Choice Compact Waiver. In exchange for a cap on combined federal and state spending of $12.075 billion through 2013, Rhode Island received greater flexibility to adopt certain Medicaid program changes. This study analyzes the design and implementation of the Global Waiver to draw general lessons for health reform at the state-level, a key concern given ongoing state discretion to improve their health care systems under the Patient Protection and Affordable Care Act. Data …

Coercion, Compulsion, And The Medicaid Expansion: A Study In The Doctrine Of Unconstitutional Conditions, Mitchell N. Berman

All Faculty Scholarship

The Supreme Court’s decision in National Federation of Independent Business v. Sebelius regarding the constitutionality of the Patient Protection and Affordable Care Act produced three main holdings concerning two critical provisions of the Act. The first two holdings concerned the “individual mandate” that requires most Americans to maintain “minimum essential” health insurance. The third holding concerned “the Medicaid expansion,” which expanded the class of persons to whom the states must provide Medicaid coverage as a condition for receiving federal funds under the Medicaid program. By a vote of 7-2, the Court struck down this provision as an impermissible condition on …

Funding Health-Related Vr Services: The Potential Impact Of The Affordable Care Act On The Use Of Private Health Insurance And Medicaid To Pay For Health-Related Vr Services, Robert Silverstein

All Institute for Community Inclusion Publications

One of the myriad of issues affecting the administration of the vocational rehabilitation (VR) program by State VR agencies under Title I of the Rehabilitation Act is how to maximize access to and use of all available funding sources to pay for VR services and supports for VR applicants and clients. In March 2010, Congress passed and the President signed into law the "Affordable Care Act" (ACA). 1 On June 28, 2012, the United States Supreme Court upheld all of the provisions of the ACA, with the exception of provisions mandating Medicaid expansion. The Supreme Court held that if a …

The Power To Block The Affordable Care Act: What Are The Limits?, John D. Kraemer, Lawrence O. Gostin

Georgetown Law Faculty Publications and Other Works

Though Supreme Court upheld most parts of the Affordable Care Act (ACA), Congress’ goals in enacting it could still be frustrated by non-implementation. During his campaign for president, Governor Romney promised “to issue Obamacare waivers to all fifty states.” While such blanket waivers would likely violate the Constitution’s Take Care Clause, the ACA does permit other waivers. To be lawful, however, they must meet certain requirements designed to enhance access and lower cost. A president who opposes the ACA might be able to limit its implementation by refusing to issue premium subsidies in federally operated insurance exchanges, and this might …

Affordable Care Act Litigation: The Supreme Court And The Future Of Health Care Reform, Lawrence O. Gostin, Kelli K. Garcia

Georgetown Law Faculty Publications and Other Works

In Florida v. HHS, a lawsuit brought on behalf of 26 states challenging the constitutionality of the Patient Protection and Affordable Care Act (ACA), the Supreme Court will determine the future direction of health care reform in the United States. During the unprecedented 5-1/2 hours of oral arguments, the Court will hear 4 issues: the individual purchase mandate, severability, the Medicaid expansion and the Anti-Injunction Act.

The states challenging the ACA maintain that the purchase mandate uniquely penalizes individuals for failing to purchase insurance. Uninsured individuals, however, rarely do nothing. Instead, they self-insure, rely on family, and cost-shift to …

Counting The Cost, Marc A. Clauson

History and Government Faculty Publications

No abstract provided.

Institute Brief: Minimum Wage Increase: A Guide For Disability Service Providers (Updated 2009), David Hoff

The Institute Brief Series, Institute for Community Inclusion

This publication provides guidance to service providers regarding the increase in minimum wage, with a particular focus on assisting consumers with questions and concerns they may have regarding the impact on their public benefits.

Data Note: Ssi Recipients With Disabilities Who Work And Participation In 1619b, Brooke Dennee-Sommers, Frank A. Smith

Data Note Series, Institute for Community Inclusion

Supplemental Security Income (SSI) is a federally funded program that provides cash assistance for basic needs. Individuals with a low-income who are over the age of 65, blind, or have a disability are eligible for assistance. SSI beneficiaries typically also receive health insurance coverage through Medicaid. Losing Medicaid benefits can be of concern for SSI recipients with disabilities who desire to work, or are currently working. Section 1619b of the Social Security Act allows individuals to work and continue to receive Medicaid assistance when their earnings are too high to qualify for SSI cash payments as long as they meet …

Research To Practice: Medicaid Involvement In Employment-Related Programs- Findings From The National Survey Of State Systems And Employment For People With Disabilities, Jennifer Sullivan Sulewski, Dana Scott Gilmore, Susan Foley

Research to Practice Series, Institute for Community Inclusion

This brief analyzes data from ICI's National Survey of State Systems and Employment for People with Disabilities regarding the priority Medicaid agencies place on employment and their involvement in recent policy initiatives.

Research To Practice: Collaboration Between Medicaid And Other State Agencies- Findings From The National Survey Of State Systems And Employment For People With Disabilities, Jennifer Sullivan Sulewski, Dana Scott Gilmore, Susan Foley

Research to Practice Series, Institute for Community Inclusion

Many state Medicaid agencies are playing a greater role in multi-agency efforts to promote employment for people with disabilities. This brief uses data from the National Survey of State Systems and Employment for People with Disabilities to explore the varieties of collaboration Medicaid agencies are using and the agencies they are collaborating with.

Policy Brief: The Ticket To Work And Self-Sufficiency Program And Established Under The Ticket To Work And Work Incentives Improvement Act Of 1999, Robert Silverstein

Policy Briefs Series, Institute for Community Inclusion

A description of the major provisions in Title I of the Act, which created the Ticket to Work and Self-Sufficiency Program.

Tools For Inclusion: Understanding The Ssi Work Incentives, John Butterworth

Tools for Inclusion Series, Institute for Community Inclusion

Information about Social Security Administration programs that can help people who receive Supplemental Security Income (SSI) to retain benefits that can support and ensure long-term employment.