Colleen M. Grogan

Between Welfare Medicine and Mainstream Entitlement: Medicaid at the Political Crossroads

As the new century begins, the Medicaid program is arguably at a political crossroads. Over the 1980s and 1990s, policy makers enacted major expansions in Medicaid coverage, offering significant new health benefits to poor women and children and other constituencies. In elite rhetoric and political framing, Medicaid was increasingly cast as a broad-based social welfare entitlement of value to all Americans, including middle-class citizens. Some health care advocates began viewing Medicaid expansions as a potential path to achieving universal coverage in the United States. Yet Medicaid remains a means-tested program that has been repeatedly threatened with policy retrenchment. In this essay, we scrutinize Medicaids current status and future possibilities from a historical-institutional perspective by tracing its complex evolution since its enactment in the Social Security Amendments of 1965. Our core claim is that decisions made at the time of Medicaids original adoption have fundamentally set the matrix for struggles over the programs unfolding development. We demonstrate that key ambiguities embedded in the 1965 act created largely unintended opportunities for policy entrepreneurs to broaden Medicaids scale and scope as well as foreseeable vulnerabilities that must be overcome if Medicaid is to realize its full potential.

Despite Resources From The ACA, Most States Do Little To Help Addiction Treatment Programs Implement Health Care Reform

The Affordable Care Act (ACA) dramatically expands health insurance for addiction treatment and provides unprecedented opportunities for service growth and delivery model reform. Yet most addiction treatment programs lack the staffing and technological capabilities to respond successfully to ACA-driven system change. In light of these challenges, we conducted a national survey to examine how Single State Agencies for addiction treatment--the state governmental organizations charged with overseeing addiction treatment programs--are helping programs respond to new requirements under the ACA. We found that most Single State Agencies provide little assistance to addiction treatment programs. Most agencies are helping programs develop collaborations with other health service programs. However, fewer than half reported providing help in modernizing systems to support insurance participation, and only one in three provided assistance with enrollment outreach. In the absence of technical assistance, it is unlikely that addiction treatment programs will fully realize the ACAs promise to improve access to and quality of addiction treatment.

Transitions from Private to Public Health Coverage among Children: Estimating Effects on Out-of-Pocket Medical Costs and Health Insurance Premium Costs

OBJECTIVE To assess the effects of transitions from private to public health insurance by children on out-of-pocket medical expenditures and health insurance premium costs. DATA SOURCES Data are drawn from the 1996 and 2001 panels of the Survey of Income and Program Participation. We construct a nationally representative, longitudinal sample of children, ages 0-18, and their families for the period 1998-2003, a period in which states raised public health insurance eligibility rates for children. STUDY DESIGN We exploit the Survey of Income and Program Participations longitudinal design to identify children in our sample who transition from private to public health insurance. We then use a bootstrapped instrumental variable approach to estimate the effects of these transitions on out-of-pocket expenditures and health insurance premium costs. PRINCIPAL FINDINGS Children who transition from private to public coverage are relatively low-income, are disproportionately likely to live in single-mother households, and are more likely to be Black or of Hispanic origin. Child health status is highly predictive of transitions. We estimate that these transitions provide a cash-equivalent transfer of nearly U.S.

Universalism within Targeting: Nursing Home Care, the Middle Class, and the Politics of the Medicaid Program

1,500 annually for families in the form of reduced out-of-pocket and health insurance premium costs. CONCLUSIONS Transitions from private to public health coverage by children can bring important social benefits to vulnerable families. This suggests that instead of being a net societal cost, such transitions may provide an important social benefit.

Lessons From Medicaid’s Divergent Paths On Mental Health And Addiction Services

In contrast to “targeting within universalism,” in which extra benefits are directed to low‐income groups within the context of a universal policy design, the reliance of mainstream elderly on means‐tested Medicaid benefits represents the inverse pattern of “universalism within targeting.” During moments of intense debate, policy elites have strategically reframed Medicaid as a broad‐based social entitlement, yet many politicians remain ambivalent about using a program originally intended for the poor to protect the middle class. The analysis suggests that universalism and targeting are best seen not as fixed, technical features of program structures but rather, as the political raw materials with which politicians contest the multiple and conflicting purposes of the American welfare state.

Deliberative Democracy in Theory and Practice: Connecticut's Medicaid Managed Care Council

Over the past fifty years Medicaid has taken divergent paths in financing mental health and addiction treatment. In mental health, Medicaid became the dominant source of funding and had a profound impact on the organization and delivery of services. But it played a much more modest role in addiction treatment. This is poised to change, as the Affordable Care Act is expected to dramatically expand Medicaids role in financing addiction services. In this article we consider the different paths these two treatment systems have taken since 1965 and identify strategic lessons that the addiction treatment system might take from mental healths experience under Medicaid. These lessons include leveraging optional coverage categories to tailor Medicaid to the unique needs of the addiction treatment system, providing incentives to addiction treatment programs to create and deliver high-quality alternatives to inpatient treatment, and using targeted Medicaid licensure standards to increase the quality of addiction services.

The Affordable Care Act Transformation of Substance Use Disorder Treatment

Despite calls for greater deliberation among citizens on public policy, we have little information about how existing deliberation is structured or how well it works. We examine Connecticuts effort to put public deliberation to work in Medicaid policy-making. Findings from our participant-observation study and in-person interviews with 100 participants in this process suggest some important qualifications to literature on public deliberation. Greater inclusion of diverse social groups from the target population is important, but this should not replace the inclusion of professional advocates since the latter are often more willing than citizen representatives to challenge policy experts on technical issues. Incorporating public deliberation into the process at an early stage is ideal, but deliberation during the later stages of policymaking (including during implementation) can still produce useful results. Finally, the style and purpose of deliberation can shape the range of topics on the agenda, so it is important to understand how the structure of a deliberative forum can affect the style and purpose of deliberation. The essence of democracy itself is now widely taken to be deliberation, as opposed to voting, interest aggregation, constitutional rights, or even self-government. (Dryzek 2000, 1).

Rhetoric and Reform in Waiver States

The authors reflect on changes involving substance use disorder (SUD) treatment under the U.S. Patient Protection and Affordable Care Act (ACA), and it mentions American President Barack Obamas public health legacy, as well as the potential impact that the ACA will have on an opioid epidemic in the country. Medications for opioid use disorder patients are examined, along with health insurance coverage for SUD treatment services and the U.S. 2008 Mental Health Parity and Addiction Equity Act.

The Racial Divide in State Medicaid Expansions

Seven states have used Section 1115 waivers to expand Medicaid as part of the Affordable Care Act (ACA). While each state pursued a unique plan, there are similarities in the types of changes each state desired to make. Equally important to how a state modified their Medicaid programs is how a state talked about Medicaid and reform. We investigate whether the rhetoric that emerged in waiver states is unique, analyze whether the rhetoric is associated with particular waiver reforms, and consider the implications of our findings for the future of Medicaid policy making. We find that proponents in waiver states have convinced a conservative legislature that their reform is sufficiently innovative that they are not doing a Medicaid expansion, and not building on the traditional Medicaid program. Particularly striking is that none of these reforms are entirely new to the Medicaid program. While not new, the way in which waiver states have been allowed to implement many of the reforms is new and has become stricter. We find an emerging consensus utilized by conservative policy makers in framing the Medicaid expansion. Expansion efforts by conservative policy makers in other states have subsequently pushed this framing far to the right.

Could the President and Congress Precipitate a Public Health Crisis

This study considers five important questions related to the role of race in state-level public support for the Medicaid expansion: (1) whether public support for the Medicaid expansion varies across the American states; (2) whether public support is positively related to state adoption; (3) whether this support is racialized; (4) whether, if racialized, there is evidence of more state responsiveness to white support than to nonwhite (black and/or Latino) support; and (5) does the size of the nonwhite population matter more when white support is relatively low? Our findings suggest that while public support for the Medicaid expansion is high at the state level, especially in comparison to public support for the ACA, there are important variations across the states. Although overall public support is positively related to state adoption, we find that public support for the Medicaid expansion is racialized in two ways. First, there are large differences in support levels by race; and second, state adoption decisions are positively related to white opinion and do not respond to nonwhite support levels. Most importantly, there is evidence that when the size of the black population increases and white support levels are relatively low, the state is significantly less likely to expand the Medicaid program. Our discussion highlights the democratic deficits and racial bias at the state level around this important coverage policy.