Medicaid And Devolution

How much responsibility for providing health care to the poor should be devolved from the federal government to the states? Any answer to this critical policy question requires a careful assessment of the Medicaid program. Drawing on the insights of leading scholars and top state health care officials, this volume analyzes the policy and management implications of various options for Medicaid devolution. Proponents of devolution typically express confidence that states can meet the challenges it will pose for them. But, as this book shows, the degree to which states have the capacity and commitment to use enhanced discretion to sustain or improve health care for the poor remains an open question. Their failure to attend to issues of politics, implementation, and management could lead to disappointment. Chapters focus on such topics as Medicaid financing, benefits and beneficiaries, long-term care, managed care, safety net providers, and the appropriate division of labor between the federal government and the states. The contributors are Donald Boyd, Center for the Study of the States; Lawrence D. Brown, Columbia University; James R. Fossett, Rockefeller College; Richard P. Nathan, Nelson A. Rockefeller Institute of Government, State University of New York, Albany; Michael Sparer, Columbia University; James Tallon, United Hospital Fund; and Joshua M. Weiner, the Urban Institute.

The balance between state and federal health care financing for low-income people has been a matter of considerable debate for the last 40 years. Some argue for a greater federal role, others for more devolution of responsibility to the states. Medicaid, the backbone of the system, has been plagued by an array of problems that have made it unpopular and difficult to use to extend health care coverage. In recent years, waivers have given the states the flexibility to change many features of their Medicaid programs; moreover, the states have considerable flexibility to in establishing State Children's Health Insurance Programs. This book examines the record on the changing health safety net. How well have states done in providing acute and long-term care services to low-income populations? How have they responded to financial incentives and federal regulatory requirements? How innovative have they been? Contributing authors include Donald J. Boyd, Randall R. Bovbjerg, Teresa A. Coughlin, Ian Hill, Michael Housman, Robert E. Hurley, Marilyn Moon, Mary Beth Pohl, Jane Tilly, and Stephen Zuckerman.

Medicaid is a story worth telling, one rooted in American history and shaped by its culture and institutions. It has dramatic interest, heroes and heroines, triumphs and tragedies. The authors make this story come alive for the reader by providing a strong connected narrative, detailed accounts of important policy changes, and extensive use of interviews with individuals close to events. They emphasize politics and policy along with history. History is important because Medicaid has developed incrementally, layer by layer, so that almost any provision or activity needs a historical gloss to understand it. The Medicaid program has been especially subject to outside political and policy influences: the state of the economy, trends in federalism, developments in health or welfare programs, and the electoral cycle. Politics helps us understand policy outcomes. But the two go together: a knowledge of policy helps understand what is at stake, and a knowledge of politics what is possible. A central theme of the book is that Medicaid is a "weak entitlement," one less established or effectively defended than Medicare or Social Security, but more secure than welfare or food stamps. Medicaid has the flexibility to adapt (or be adapted) as well as a capacity to defend incremental and opportunistic gains. At the same time, the program lacks an effective mechanism for overall reform. It has grown enormously since its inception to become the largest health insurance system in the country, a source of perennial complaint and, most recently, of continuing crisis. The dual emphasis upon politics and policy is important to make the arcane Medicaid program accessible to the reader, and to distinguish policy grounded in facts and analysis from partisan bombast and ideology. The result is an authoritative account and reference for those seeking to refresh a perspective or to look further.

Explore significant—but often-overlooked—aspects of aging policy! This unique addition to the literature on aging policy will help you understand devolution—the decentralizing of service provision—and the roles that state/local government and private organizations now play in addressing the needs of our aging population. It will show you how to initiate innovations and make positive changes in aging policy through state and local initiatives, collaborations between the federal government and other government agencies, public/private collaboration, and strictly private initiatives. From the editors: “Around the world, the ground rules are being questioned about the role of national governments in addressing domestic needs. During the twentieth century in countries throughout the world, central governments assumed major responsibilities for a wide variety of human needs. Whether the concern was income security, health, housing, or education, interventions were premised upon convictions that a strong public sector role was essential and that major involvement of national governments was needed. More recently, a significant pattern [devolution] has emerged in many countries wherein these responsibilities have shifted away from national governments to regional and local governments as well as from the public to the private sector.” Thoughtfully divided into five sections that illustrate distinctly different forms of devolution, this book first provides an essential overview of devolution and then examines its implications for vital aspects of service provision to the elderly. In the United States in recent years, the single greatest focus for devolution has been the transformation of income security protections for poor families. The federal Aid to Families With Dependent Children program has been replaced by the Temporary Assistance to Needy Families program. Devolution and Aging Policy examines that change and other important facets of the current climate of devolution, including: Medicaid-financed long-term care state sponsorship of services in retirement communities the implications of the Workforce Investment Act for the access of older workers to training at a state level to upgrade their work skills public/private sector collaboration in long-term care insurance long-term care ombudsman programs what state governments can do to help elders make use of information technology property tax credits for seniors that are given in exchange for volunteering on the municipal level how an HMO can encourage and stimulate service coordination and more!

Perhaps the most glaring failure of the American mixed public/private health care system is that millions, including many of the most vulnerable, go without health insurance. In Running in Place, Eliot Fishman analyzes the various means-tested health insurance initiatives instituted at the state level since the 1960s and finds that, while there have been successes, on the whole these programs have never come close to fulfilling expectations regarding increasing the numbers of low-income people enrolled or their access to mainstream health providers.Fishman argues that such state-administered measures, modeled on Medicaid, the oldest and largest of the programs, will not bring the nation close to the goal of universal coverage. At the same time, sweeping reforms that have been proposed, such as a federally administered single-payer plan, are not feasible given the current political atmosphere in Washington. Steering between these two poles —retaining the decentralizing features of the Medicaid model that make it popular while increasing its effectiveness —will require that the federal government assume more of the fiscal burden even as states continue to run their own programs. More people will be covered if enrollment becomes automatic, with eligibility verified retrospectively, and the appeal of such programs will increase if they are broadened to include working families who are having trouble finding affordable insurance.

In this report, Paul Offner explores the impact of the shift toward greater state responsibility for managing Medicaid. Offner argues not only that the balance has shifted too far toward the states, but also that it would be better if the federal government ran the program entirely.

Medicaid is the single largest public health insurer in the United States, covering upwards of 70 million Americans. Crucially, Medicaid is also an intergovernmental program that yokes poverty to federalism: the federal government determines its broad contours, while states have tremendous discretion over how Medicaid is designed and implemented. Where some locales are generous and open handed, others are tight-fisted and punitive. In Fragmented Democracy, Jamila Michener demonstrates the consequences of such disparities for democratic citizenship. Unpacking how federalism transforms Medicaid beneficiaries' interpretations of government and structures their participation in politics, the book examines American democracy from the vantage point(s) of those who are living in or near poverty, (disproportionately) Black or Latino, and reliant on a federated government for vital resources.

Medicaid, one of the largest federal programs in the United States, gives grants to states to provide health insurance for over 60 million low-income Americans. As private health insurance benefits have relentlessly eroded, the program has played an increasingly important role. Yet Medicaid’s prominence in the health care arena has come as a surprise. Many astute observers of the Medicaid debate have long claimed that “a program for the poor is a poor program� prone to erosion because it serves a stigmatized, politically weak clientele. Means-tested programs for the poor are often politically unpopular, and there is pressure from fiscally conservative lawmakers to scale back the $350-billion-per-year program even as more and more Americans have come to rely on it. For their part, health reformers had long assumed that Medicaid would fade away as the country moved toward universal health insurance. Instead, Medicaid has proved remarkably durable, expanding and becoming a major pillar of America’s health insurance system. In Medicaid Politics, political scientist Frank J. Thompson examines the program’s profound evolution during the presidential administrations of Bill Clinton, George W. Bush, and Barack Obama and its pivotal role in the epic health reform law of 2010. This clear and accessible book details the specific forces embedded in American federalism that contributed so much to Medicaid’s growth and durability during this period. It also looks to the future outlining the political dynamics that could yield major program retrenchment.

In 1965, the United States government enacted legislation to provide low-income individuals with quality health care and related services. Initially viewed as the friendless stepchild of Medicare, Medicaid has grown exponentially since its inception, becoming a formidable force of its own. Funded jointly by the national government and each of the fifty states, the program is now the fourth most expensive item in the federal budget and the second largest category of spending for almost every state. Now, under the new, historic health care reform legislation, Medicaid is scheduled to include sixteen million more people. Laura Katz Olson, an expert on health, aging, and long-term care policy, unravels the multifaceted and perplexing puzzle of Medicaid with respect to those who invest in and benefit from the program. Assessing the social, political, and economic dynamics that have shaped Medicaid for almost half a century, she helps readers of all backgrounds understand the entrenched and powerful interests woven into the system that have been instrumental in swelling costs and holding elected officials hostage. Addressing such fundamental questions as whether patients receive good care and whether Medicaid meets the needs of the low-income population it is supposed to serve, Olson evaluates the extent to which the program is an appropriate foundation for health care reform.