Medicaid programs and policy overview

HEALTH POLICY ANALYSIS: NURSING & MEDICAID

Medicaid Policy Analysis

The Plight of the Poor and Medicaid Policy Framework

Visible and Vocal Advocate

Inherent Inequality in American Democracy

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

Questions Addressed in this Study

Analysis & Evaluation

HEALTH POLICY ANALYSIS: NURSING & MEDICAID

The objective of the following work in writing is to examine Medicaid policy and to answer questions including those of: (1) What necessitated or facilitated the creation of the policy? (2) What was the policy attempting to accomplish? (3) Who had input into the development of the policy? (4) Was public comment solicited prior to the finalization of the policy? (5) for Whom Does the Policy Advocate? (6) What Purpose Does the Policy Serve in Its Health Care Arena? (7) How Is the Policy Operationalized? (8) What Are the Strengths of the Policy? (9) What Were the Limitations of the Policy? (10) What Impact Does the Policy Have on Social Justice? (11) What Is the Impact of the Policy on Vulnerable Populations? The eligibility requirements as set out in the Deficit Reduction Act of 1984 are examined in the following sections of this work in writing and examined as well is the soundness of eligibility requirements as the instrument by which alone to determine the eligibility of the poor for receiving Medicaid coverage.

I. Medicaid Policy Analysis

The work of Edward Allan Miller (2007) entitled: "Federal Administrative and Judicial Oversight of Medicaid: Policy Legacies and Tandem Institutions under the Boren Amendment" states "The role of the courts in shaping federal regulation of state policy decisions in the health sector is especially important for understanding the course of health policy in the United States. This is because, while federal statutes and regulations establish the broad parameters within which programs such as Medicaid operate, federal administrative review and judicial oversight ultimately determine whether particular policy actions fall within the scope of federal guidelines. But despite the importance of the courts, relatively few consider the relationship between the judiciary and federal regulation of state health policy decisions." (Miller, 2007)

Medicare and Medicaid were enacted in 1965 as Titles 18 and 19 and "reflected two distinct political philosophies and continue to do so. Medicare is a universalistic program: Its forty million beneficiaries constitute virtually all of the elderly who are automatically entitled to its benefits." (Brown and Sparer, 2003) There are approximately forty-million enrollees in Medicaid and this group is comprised of individuals who meet eligibility rules set by the states and shaped partially by federal mandates. Brown and Sparer states that those who advocate for U.S. national health insurance "tend to share an image that highlights universal standards of coverage, social insurance financing, and national administration -- in short, the basic features of Medicare." (2003)

While this approach is held to be equitable and efficient or to be "good policy and equally good politics" simultaneously Medicaid "is often taken to exemplify poor policy and poorer politics: means-tested eligibility, general revenue financing, and federal/state administration, which encourages inequities and disparities of care." (Brown and Sparer, 2003) Medicaid emerged "as a comprehensive health coverage for people who could not afford to buy care through private means. The program has contrived to stabilize its benefits and expand its number of beneficiaries with success that is surprising in a poor people's program." (Brown and Sparer, 2003) Medicaid however, "...lacking a universalistic mandate" resulted in the leaders of the Medicaid program giving consideration to "tightening eligibility when costs rose too fast or state revenues sank too low." (Brown and Sparer, 2003)

The federal government has expanded and alternatively reduced eligibility and then passed these mandates on to the states which often failed to adopt these new eligibility standards. For example the federal government required expanded Medicaid coverage, "...demanding that states give eligibility to poor women and children at more inclusive income and age limits. States duly protested these mandates, but Washington turned a deaf ear." (Brown and Sparer, 2003) Medicaid relies on general revenues and this in itself "should make it a political football, and 'soaring' rates of Medicaid spending have indeed generated considerable heat." (Brown and Sparer, 2003)

The reliance on Medicaid on general revenues (both state and federal) is stated by Brown and Sparer to have "encouraged strategic improvisations to which trust funding has been less conducive. States spending as little as twenty-three cents and no more than fifty cents of their own funds in each Medicaid dollar find that it pays to be creative in the search for disproportionate-share hospital (DSH) payments, federal waivers, upper payments limits, and other pots of gold." (Brown and Sparer, 2003)

II. The Plight of the Poor and Medicaid Policy Framework

Brown and Sparer (2003) state that Medicaid presently is affected by a challenge "its creators could not have foreseen in 1965: While the U.S. medical world has shifted massively to managed care arrangements, Medicare remains centered on a fee-for-service, third party payment model that was mainstream, indeed near ubiquitous thirty-five years ago." (2003) Medicaid is a joint federal-state endeavor which "combines a framework of federal rules and guidance with fifty varieties of state-plan relations." (Brown and Sparer, 2003)

Brown and Sparer state that the needs of Medicaid have "steadily expanded and now stretch beyond the impoverished women and children with whom the program is popularly identified. Roughly two-thirds of Medicaid spending serves the aged, blind, and disabled, who are about one-quarter of its beneficiaries. The equation of poor people's programs with poor programs failed to capture how heterogeneous and capacious the categories of entitlement would become as the politics of social policy played on." (Brown and Sparer, 2003)

III. The Nurses: Visible and Vocal Advocate

The work of Lundy, Lundy and Janes (2009) entitled: "Community Health Nursing: Caring for the Public's Health" states that public opinion is "expressed through special interest groups" and is "very influential in the development of public policy." (Lundy, Lundy and Janes, 2009) Many special interest groups including the American Hospital Association, the American Medical Association, and the American Insurance Association "spend huge amounts of time and money providing legislators with information on which to base health care decisions." (Lundy, Lundy and Janes, 2009) it does not help that many legislators are lacking in an in-depth understanding of health care issues" because the result is that the "information provided by special-interest groups often serves as a basis for health care decisions. When that happens decisions may fail to reflect the best interests of the majority." (Lundy, Lundy and Janes, 2009)

Lundy, Lundy and Janes states that nurses "...as the largest health care provider groups" need to be "both visible and vocal advocates for quality health care." (2009) Meeting that goal has been the focus of the American Nurses Association (ANA) which has "worked tirelessly over the years to develop an effective special-interest group infrastructure." (Lundy, Lundy and Janes, 2009) in 2007 the ANA "formulated a position paper stating that the U.S. health care systems needs restructuring, wellness promotion must become our emphasis, and universal access to health care services must be developed." (Lundy, Lundy and Janes, 2009) the ANA has further been active politically in several areas which include the area of health care rationing.

IV. Inherent Inequality in American Democracy

It is reported in the work of Jacobs and Skocpol (2007) entitled: "Inequality and American Democracy: What We Know and What We Need to Learn" that a recent and unpublished analysis of policy changes and public opinion which investigates the "possibility of unequal responsiveness to the policy preferences of rich and poor citizens." Reports a study which used data from 755 survey questions between the years of 1992 and 1999 "in which national samples of the public were asked about proposed changes in U.S. national policy." (Jacobs and Skocpol, 2007) This two-step procedure estimated the relationship between income and policy preferences for each of these 755 questions, the related the preferences of survey respondents at various income levels separately to actual changes in corresponding public policy." (Jacobs and Skocpol, 2007) f

Findings in the study indicate that a 10 percentage point increase in support for policy change among citizens at the ninetieth percentile of the income distribution was associated with a 4.8 percentage point increase in the likelihood of a corresponding policy shift." (Jacobs and Skocpol, 2007) it is stated that for the 300 policy question in which the imputed preferences of rich and poor citizens differed by 10 percentage points or more the disparities in apparent influence were even more stark, with a 10 percentage point shift in opinion among the poor associated with only a 9.5 percentage point difference in the likelihood of policy change. The analysis of national opinion and policy "suggests that the American political system is a great deal more responsive to the preferences of the rich than to the preferences of the poor." Jacobs and Skocpol, 2007)

It is stated that research demonstrates that there are "large differences in the nature, timing and effectiveness of state regulation efforts." (Jacobs and Skocpol, 2007) a comparative case study of California and New York is stated to indicate that "their distinctive political processes produced divergent approaches to controlling Medicaid costs and widening access to medical care for the poor: California officials extended the most generous Medicaid benefits of all fifty states, while New York's Medicaid program was twice the cost, dominated by interest groups, and offered less access." (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 has been reviewed are listed in the following section of this work.

VI. 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)