Health Policy Commons^™

Medicaid Expansions & Public Health Spending: Cross-Subsidies, Complementarities, And Crowd-Out, Glen P. Mays

Health Management and Policy Presentations

In this paper we estimate the causal impact of state Medicaid enrollment expansions and expenditures on state and local resources allocated to other public health programs and services. Using a quasi-experimental design with instrumental variables estimation, we find evidence that increased Medicaid spending leads to reduced governmental spending on other public health services, consistent with a crowd-out effect. Over 10 years, such crowd-out has the potential to diminish the health status improvements generated through health insurance coverage expansions.

An Analysis Of Political And Legal Debates Concerning Medicaid Expansion In Virginia, Rick Mayes, Benjamin Paul

Political Science Faculty Publications

The Supreme Court’s historic June 2012 ruling regarding the Affordable Care Act (ACA) in National Federation of Independent Business v. Sebelius set the stage for a massive federalism battle over Medicaid expansion in the United States. The original language of the Act was intended to nationalize Medicaid by having every state expand their program’s eligibility to all individuals up to 138% of the federal poverty level. This would have significantly reshaped Medicaid, a joint federal-state health insurance program, into a universal entitlement for all low-income citizens. Currently, Medicaid eligibility varies dramatically from state to state. The Court held that the …

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 …

Implications Of The Affordable Care Act's Medicaid Expansion On Low-Income Individuals On Probation, Marsha Regenstein, Lea Nolan

Health Policy and Management Faculty Publications

Every year, millions of Americans become involved in the local criminal justice system and are held in jails, placed on probation, or some combination of the two. This paper focuses on the probation population, a group of individuals who receive correctional supervision in communities, generally as an alternative to incarceration. Individuals on probation are disproportionately low-income and uninsured; many are likely to qualify for health coverage through state Medicaid expansions and private insurance Marketplaces that are part of the Patient Protection and Affordable Care Act. Opening up access to affordable health insurance coverage for this vulnerable group of individuals is …

Strategies For Health Care Cost Containment (1980s-Present), Rick Mayes

Political Science Faculty Publications

The U.S. health care system during the past three decades has been over two interrelated questions: first, who will control the manner in which medical care is paid for, and, second, how much will it cost? Many health care experts believe that Medicare's efforts at cost control, primarily in the form of the program's seminal transition to and continual modification of prospective payment of health care providers, has both triggered and repeatedly intensified the economic restructuring of the U.S. health care system. Medicare is an almost $600 billion public health insurance program for individuals sixty-five years of age and older; …

Quality Of Care In Community Health Centers And Factors Associated With Performance, Julia Paradise, Peter Shin, Jessica Sharac, Sara J. Rosenbaum, Kaiser Commission On Medicaid And The Uninsured

Health Policy and Management Issue Briefs

This study examines quality performance among community health centers (CHC) on three key measures of primary and preventive care — diabetes and blood pressure control and timely Pap tests — using quality in Medicaid managed care organizations (MCO) as a benchmark. The study also identifies factors that differ significantly between high- and lower-performing health centers. Most health centers perform better than 75% of all Medicaid MCOs on the two chronic care measures, and more than 1 in 10 exceed this benchmark on all three quality measures. Few health centers lag behind average Medicaid MCO performance on all three measures. Lower-performing …

Government Provided Health Insurance, Kristina Lambert, Ryan O’Connor

Academic Symposium of Undergraduate Scholarship

No abstract provided.

Community Health Centers In An Era Of Health Reform: An Overview And Key Challenges To Health Center Growth, Peter Shin, Jessica Sharac, Carmen Alvarez, Sara J. Rosenbaum, Julia Paradise

Health Policy and Management Faculty Publications

Over 1,100 federally funded community health centers play a vital role in ensuring access to health care for a predominantly low-income population in medically underserved communities. Health centers’ ability to provide comprehensive primary care and improve access to high-quality care while holding down health care cost growth has been well-documented. As health reform spurs coverage expansion and efforts to improve quality, the nation’s reliance on health centers is likely to grow.

In the Affordable Care Act (ACA), Congress invested $11 billion over five years to expand the health center program, to broaden access to care in lower-income communities as coverage …

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 …

Medicaid Coverage For Individuals In Jail Pending Disposition: Opportunities For Improved Health And Health Care At Lower Costs, Marsha Regenstein, Jade Christie-Maples

Health Policy and Management Faculty Publications

The Patient Protection and Affordable Care Act (ACA) provides an unprecedented opportunity for millions of poor men and women to obtain insurance coverage to address their substantial acute, chronic, physical and behavioral health care needs. The ACA raises Medicaid eligibility levels to 133 percent of poverty, thereby enabling adults with or without children to qualify for coverage. A substantial percentage of the newly eligible population will be jail-involved individuals – people who have had interactions with the legal system over the course of a year, including as an inmate at a county or city jail. Many of these individuals are …

Increasing Consumer Involvement In Medicaid Nursing Facility Reimbursement: Lessons From New York And Minnesota, Edward Alan Miller, Cynthia Rudder

Gerontology Institute Publications

Medicaid is the major purchaser of nursing home care in the United States. States design their methods of reimbursing nursing homes to achieve desired policy objectives related to facility cost and quality, access to care, payment equity, service capacity, and budgetary control. The incorporation of multiple, sometimes conflicting incentives into state reimbursement systems has resulted in enormously complex and demanding methodologies that inhibit consumer participation in state rating setting decisions. In turn, the lack of consumer involvement has the potential to result in the adoption of reimbursement systems that favor industry and government interests at the expense of issues important …

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 …

Consumer Involvement In Medicaid Nursing Facility Reimbursement: Lessons From New York And Minnesota For State Policymakers, Edward Alan Miller, Cynthia Rudder

Gerontology Institute Publications

Medicaid is the major purchaser of nursing home care in the United States. State governments design their methods of reimbursing nursing homes to achieve desired policy objectives related to facility cost and quality, access to care, payment equity, service capacity, and budgetary control.

Often, participation in the process of developing Medicaid payment policy is limited to state agency officials and providers of care and, occasionally, union representatives and state legislative staff. Invited less frequently to reimbursement policy discussions are consumer representatives. Lack of consumer involvement in the development of state rate setting systems has the potential to result in the …

A Primer For Consumer Involvement In Medicaid Nursing Facility Reimbursement: Lessons From New York And Minnesota, Edward Alan Miller, Cynthia Rudder

Gerontology Institute Publications

Medicaid is the major purchaser of nursing home care in the United States. To ensure that providers behave appropriately, the federal and state governments have established an extensive set of regulations that nursing homes must comply with if they are to be reimbursed for patients insured by Medicaid. Consumers exert considerable influence here by focusing on regulations and enforcement of non-compliance.

States also seek to align providers’ interests with those of other interested parties through controls and incentives built into state reimbursement systems, including with respect to facility cost and quality, access to care, payment equity, service capacity, and budgetary …

The Way It Was In Health Policy, And Probably Will Be: Learning Lessons By Rashi Fein (Book Review), Rick Mayes

Political Science Faculty Publications

Learning Lessons by Rashi Fein is an enjoyable memoir from a scholar and policy adviser unlike any other. Fein’s influential involvement in health care policy dates back to John F. Kennedy’s administration, and his career as a leading health economist paralleled the significant growth in the political influence of health economists following the enactment of Medicare and Medicaid in 1965. Now an emeritus professor of the economics of medicine at Harvard Medical School, Fein writes here about the lessons he learned in medicine, economics, and public policy. His view of the policy process, as a way of coming to …

The Role Of Medicaid In Promoting Access To High-Quality, High-Value Maternity Care, Anne R. Markus, Sara J. Rosenbaum

Health Policy and Management Faculty Publications

The main purpose of this article is to analyze and describe the role of Medicaid in facilitating access to care for pregnant women and ensuring high-quality maternity care that is affordable. It first summarizes the federal Medicaid requirements regarding eligibility, coverage of benefits, financing, and service delivery, with a special emphasis on existing quality provisions. Then, it discusses current issues and recommends several Medicaid reforms, particularly in the area of quality assessment and improvement. All reforms, including Medicaid reforms, should seek to support the IOM-identified aims. Much of the emphais in Medicaid policy development has been focused on access to …

Nevada Medicaid And Check Up Programs: Barriers To Enrollment And Utilization, The Nevada Institute For Children’S Research And Policy, Denise Tanata Ashby, Jennifer Waddoups, Tara Phebus

Nevada Institute for Children's Research and Policy Reports

This study offers only a brief look at some of the barriers Nevada children and families face with Medicaid and Nevada Check Up. Strengthening the Medicaid and Nevada Check Up programs is vital to improving children’s health care access and utilization in Nevada. By developing and implementing legislation to improve public health insurance coverage, access, and utilization in Nevada, policymakers can ensure a brighter, happier, and healthier future for Nevada’s children and families.

A Trade-Off Proposal For Funding Long-Term Care, Yung-Ping Chen

Gerontology Institute Publications

Long-term care can be a depressing subject. Most of us tend not to think about it. However, we cannot long avoid it as the 76 million baby boomers begin reaching older ages in a few short years. According to projections, in 40 years, those aged 65 to 84 (numbering 31.6 million in 2005) will more than double, and those 85 plus (about 5.1 million in 2005), who are more at risk of dependency, will more than triple (U.S. Census Bureau, 2004 and 2006). Heavy reliance on Medicaid, already the second largest budget item in most states, would not appear viable. …

Medicaid And Health Information: Current And Emerging Legal Issues, Sara J. Rosenbaum, Patricia Mactaggart, Phyllis Borzi

Health Policy and Management Faculty Publications

Legal questions are an inevitable byproduct of significant technology change in health care such as that underway as a result of health information technology (HIT). This article examines several important existing and emerging legal questions in a Medicaid context. First, do the Centers for Medicare & Medicaid Services (CMS) and State Medicaid agencies, have a fiduciary obligation to adopt and fully use health information technology given its potential to improve health care quality while reducing racial, ethnic, and socioeconomic disparities in health and health care? Second, how can Medicaid privacy standards be reconciled with the Health Insurance Portability and Accountability …

Variations Among Regions And Hospitals In Managing Chronic Illness: How Much Care Is Enough?, John E. Wennberg

Center for Policy Research

Classic epidemiology looks at what happens to people who live in a defined region over time. For example, birth rate, the number of births that occur among populations over a year, is a common statistics that we're all familiar with. Since the early 1990s we have conducted research at Dartmouth Medical School to convert that classic epidemiologic perspective into looking at what is happening in terms of the health care system itself. We ask how much care people are getting in different regions of the country. We want to know the patterns of that care. And we want to get …

Changing Economic Incentives In Long-Term Care, R. Tamara Konetzka

Center for Policy Research

Just as managed care has changed utilization and incentives in other parts of health care, there is a whole set of incentives built around long-term care that really matter. For example, if nursing homes have a financial incentive to hospitalize people with certain health conditions, then in the long run they are not going to develop the programs and invest in the resources to treat those people in the facility. Instead they're going to use those resources to stay in business or to provide other types of care. And while we can assume that policymakers do not create regulations that …

California’S In-Home Supportive Services Program: Who Is Served?, Debi Waterstone, Taewoon Kang, Cristina Flores, Candace Howes, Charlene Harrington, Robert Newcomer

Economics Faculty Publications

Governor Schwarzenegger's preliminary 2004-05 Budget Bill proposed to eliminate a component of California's In-Home Supportive Services (IHSS) program serving approximately 68,000 individuals. This component, known as the Residual Program, included Protective Supervision and Domestic Care services and services provided by parents and spouses. Under the then existing regulations and the state's approved state plan for Medicaid, these services did not qualify for shared financing with the Medicaid program and were thus funded solely by state and county sources. The objective of the administration's proposal was to obtain an estimated net savings from the IHSS program in Fiscal Year 2005 of …

Universal Coverage And The American Health Care System Crisis (Again), Rick Mayes

Political Science Faculty Publications

Ten years after President Clinton’s ambitious attempt at comprehensive health care reform died, several old and new issues with the health care system have emerged. First, the number of uninsured Americans rose to 43.6 million in 2002—and the numbers have since increased. Also, the costs for those who do not have insurance are rapidly increasing. In addition health care related problems are one of the leading causes of personal bankruptcy in the United States. Finally, the government’s two primary health insurance programs—Medicare and Medicaid—are experiencing considerable financial strain. Dr. Mayes examines these problems in depth before and revisits President Clinton’s …

Medicaid, Managed Care, And Kids. 12th Annual Herbert Lourie Memorial Lecture On Health Policy, Deborah A. Freund

Center for Policy Research

This policy brief talks about what managed care for Medicaid is, how it influences kids, and how it relates to the State Child Health Insurance Program (CHIP). It focuses on what we have learned over the last 20 years through research about cost, use, and quality. It also discusses some of the expectations we had for children covered by Medicaid managed care. Finally, it talks about the future of Medicaid managed care and the implications for CHIP.

New Conundrums: Public Policy And The Emerging Health Care Marketplace, James R. Tallon

Center for Policy Research

There is a fundamentally new dynamic in American health care, one that has yet to be fully experienced but that threatens to leave a large portion of the American population without access to the quality health care they have received in the past. While the federal government has not completely abandoned the goal of assuring universal health care, a goal that dates back to the creation of Medicare and Medicaid in the 1960s and even earlier, the mechanisms to pursue that goal have changed. The implicit contract between government and health care providers--mostly doctors and not-for-profit hospitals--under which subsidized care …