" (Jacobs and Skocpol, 2007) Brown and Sparer (2003) state that Medicare is "...administered by the federal government. Not only eligibility criteria and financing policy but also the benefit package, policies governing payments to providers, and decisions about the delivery system (for instance, fee-for-service vs. managed care) are determined in Washington, D.C., with no direct participation by the states. (the program delegates important decisions about coverage and payments to third-party insurers -- fiscal intermediaries and carriers -- and thus these national determinations do not preclude considerable regional variations that reflect local differences in wage costs and other factors)." (2003) Medicaid is state-managed "...although a framework of federal rules constrains state program administrators, they retain wide, and widening, discretion on all of the basic issues: eligibility, benefits, payments, and organization of care." (Brown and Sparer, 2003)

V. Eligibility, Physician Behavior and Low-Income Population Access to Care

The work of Baker and Royalty (1997) entitled: "Medicaid Policy, Physician Behavior, and Health Care for the Low-Income Population" states that concerns relating to the health of poor children and their mothers "produced major change in the Medicaid program beginning in the early 1980s. New legislation greatly expanded the number of children and pregnant women eligible for the program, and many sates increased the fees paid to providers for treating Medicaid patients, particularly for obstetric and pediatric services." (Baker and Royalty, 1997) Stated as a primary goal central to these expansions was the improvement of health outcomes in these populations which are vulnerable through increasing their access to health care services.

Baker and Royalty state that both "eligibility and fee changes to improve access to care depends on both patient and physician behavior. Success makes a requirement of patients who are eligible for Medicaid "take up the program and seek health care, but also that there are physicians who will care for them. Although eligibility expansions appear at least superficially to be an effective way to increasing access to care, they may fail if they do not influence physicians." (1997)

The Deficit Reduction Act of 1984 (DEFRA 1984) initiated as series of changes to federal Medicaid law that was to expand Medicaid eligibility significantly. It is reported that by April 1990 "a uniform threshold had been established requiring all states to cover all pregnant women with incomes up to 133% of the federal poverty line, and giving states the option of covering pregnant women up to 185% of the poverty line." (Baker and Royalty, 1997) Findings stated in the work of Baker and Royalty include the fact that "a clear pattern emerges." Holding fees constant, Baker and Royalty find that "expanding eligibility increased physician services to the poor overall of the physicians in...[the study]... sample, but that all of this effect occurred in public settings such as public clinics and hospital clinics." (Baker and Royalty, 1997)

Findings also note that "the effects of eligibility expansions on the percent of patients who are poor are generally smaller than the effects of eligibility on care for Medicaid patients." (Baker and Royalty, 1997) Findings also show that while access to care increased in public settings that there were not increases in eligibility to access to private physicians. This is important in that public setting care demand when increased will likely result in "demands on the sources that fund public health care." (Baker and Royalty, 1997)

Public settings are incidentally believed to be the least efficient sources of care for the Medicaid population and as well the quality of care provided in public settings is also an issue since it is argued that "continuity of care, which may be an important aspect of primary health care, is not delivered as well in public settings." (Baker and Royalty, 1997) the efficacy of using eligibility "...alone as an instrument to accomplish expanded health care for the poor" is greatly questioned. (Baker and Royalty, 1997)

The ability of the states to modify the coverage for entire groups of optional beneficiaries results in their ability to lower the income eligibility standard and ultimately bringing about a reduction in the number of individuals with income low enough to meet the financial criteria required to be eligible for receiving Medicaid benefits. However, states cannot cut optional services for specific groups other than the medically need because this would be in violation of the 'comparability' requirement.

This work addresses several specific questions and has sought to answer these questions. Each question with an accompanying answer as noted in the foregoing literature which...

Questions Addressed in this Study
. 1. What Necessitated or Facilitated the Creation of the Policy?

The growing number of poor without access to healthcare in the 1980s. (Baker and Royalty, 1997; Brown and Sparer, 2003)

2. What Was the Policy Attempting to Accomplish?

DEFRA 1984 sought to improve the poor women and children in the United States access to health care services and modified the requirements for eligibility to access of this health care. (Baker and Royalty, 1997)

3. Who Had Input Into the Development of the Policy?

It is clear that the response, or lack of response, on the part of private physicians that those who formulated and developed the new eligibility rules did not consult with the private physician community in this initiative. (Baker and Royalty, 1997; Brown and Sparer, 2003)

5. Was Public Comment Solicited Prior to Finalization of the Policy?

There has been no record found in regards to public comment prior to the eligibility requirements for Medicaid stated in DEFRA 1984 to be finalized.

5. For Whom Does the Policy Advocate?

The eligibility policy advocates for poor women and children. (Baker and Royalty, 1997)

6. What Purpose Does the Policy Serve in Its Health Care Arena?

The purpose of this policy and that which it has served is the increased access to health care for mothers and children of poverty. (Baker and Royalty, 1997)

7. How Is the Policy Operationalized?

Through expansion of those who are eligible to receive health care services, and in this particular case, poor women and children, the result is that more of these poor women and children have a right to receive and access health care. (Baker and Royalty, 1997)

8. What Are the Strengths of the Policy?

The strengths found in the expansion of those eligible to receive Medicaid provisioned health care is that many more poor women and children did actually receive and access health care services than before the changes in eligibility institute by the DEFRA 1984. (Baker and Royalty, 1997)

9. What Were the Limitations of the Policy?

Limitations of the policy instituted through expansion of eligibility for Medicaid access health care has been shown the dissemination of information to those eligible for Medicaid and the physician behavior in treating these individuals in the private practice arena. (Baker and Royalty, 1997)

10. What Impact Does the Policy Have on Social Justice?

The impact of the expansion of eligibility requirements for receipt of Medicaid and access to health care has been one of great magnitude as the infant mortality rate has been reported to have been reduced since institution of these eligibility expansions for Medicaid health care access for poor women and children. (Brown and Sparer, 2003)

11. What Is the Impact of the Policy on Vulnerable Populations?

The impact of the eligibility expansion for access of health care through Medicaid has been significant however, it is noted in this study that recent mandates for states to reduce health care and specifically Medicaid expenditures will likely result in a tightening of the eligibility requirements for receipt of Medicaid and the corresponding access to health care services by poor women and children. (Baker and Royalty, 1997)

VII. Analysis & Evaluation

The expansion of eligibility requirements instituted in DEFRA 1984 served to increase the access to health care under Medicaid for poor women and children. The effectiveness of this initiative is attested to by the reduction in the infant mortality rate since these eligibility expansions. However, the impact of these expansions were not realized in full due to the behavior of physicians in receiving these individuals into their private practice and instead generally providing treatment for these individuals in the public care setting such as in hospitals and clinics and in which care is not found to be as effective for Medicaid recipients nor is care found to be efficient in these arenas.

There was no information found that related the physician community having been surveyed or their opinion welcomed in regards to these eligibility expansions for poor women and children in Medicaid and it is likely this that resulted in the limitations based on physician behavior and the full success of these expansions failing to be realized.

Summary & Conclusion

Future Medicaid initiatives that seek to expand those eligible for Medicaid and that seek to advance the individual access to health care is much more likely to realize full success if the various…