Philip Rocco

From metaphors to measures: observable indicators of gradual institutional change

Scholarship on social policy has recently emphasised the importance of gradual processes of institutional change. However, conceptual work on the identification of processes such as drift, conversion and layering has not produced clear empirical indicators that distinguish these processes from one another, posing major problems for empirical research. We argue that, in order to improve the validity of its empirical findings, scholarship on gradual change should – and can – pay more attention to issues of measurement and detection. We then contribute to this goal by clearly articulating observable indicators for several mechanisms of gradual institutional change and validating them against extant empirical work on political economy.

Implementing health care reform in the United States: Intergovernmental politics and the dilemmas of institutional design

The Affordable Care Act (ACA) was enacted, and continues to operate, under conditions of political polarization. In this article, we argue that the laws intergovernmental structure has amplified political conflict over its implementation by distributing governing authority to political actors at both levels of the American federal system. We review the ways in which the laws demands for institutional coordination between federal and state governments (and especially the role it preserves for governors and state legislatures) have created difficulties for rolling out health-insurance exchanges and expanding the Medicaid program. By way of contrast, we show how the institutional design of the ACAs regulatory reforms of the insurance market, which diminish the reforms political salience, has allowed for considerably less friction during the implementation process. This article thus highlights the implications of multi-level institutional designs for the post-enactment politics of major reforms.

Polarized Stakeholders and Institutional Vulnerabilities: The Enduring Politics of the Patient Protection and Affordable Care Act

PURPOSE We conducted a comparative study of how state-level political stakeholders affected the implementation of 3 major reforms within the Patient Protection and Affordable Care Act (ACA). Our goal was to analyze the effects of policy legacy, institutional fragmentation, and public sentiments on state obstruction of the reform. METHODS We gathered quantitative and qualitative evidence to generate cross-case comparisons of state implementation of 3 reform streams within the ACA: health insurance exchanges, Medicaid expansion, and regulatory reform. Our sources included secondary literature, analysis of official decisions, and background interviews with experts and public officials. FINDINGS We found that state-level opponents of the ACA were most likely to be successful in challenging reforms with few preexisting policy legacies, high institutional fragmentation, and negative public sentiments. Reforms that built on existing state legislation, avoided state veto points or offered lucrative fiscal incentives, and elicited less negative public reaction were less likely to be contested. IMPLICATIONS Our findings point to the importance of institutional design for the role of political stakeholders in implementing reforms to improve the cost, quality, and availability of medical treatments. Although other research has found that political polarization has shaped early ACA outcomes, comparative analysis suggests political stakeholders have had the highest effect on reforms that were particularly vulnerable.

Caregiver Integration During Discharge Planning for Older Adults to Reduce Resource Use: A Metaanalysis

To determine the effect of integrating informal caregivers into discharge planning on postdischarge cost and resource use in older adults.

Informal Caregiving and the Politics of Policy Drift in the United States

ABSTRACT Informal caregivers play an increasingly important role in caring for aging Americans. Yet existing social policies that could support informal caregiving have experienced “policy drift,” a failure to adapt to social risks that develop after policies are initially enacted. This article examines policy makers’ success at updating seven major policies to address caregiver needs. It draws on an original data set of legislation in this area introduced between 1991 and 2006 (n = 96). Findings indicate that drift is more likely when policy updates are costly, lack support from members of majority parties in the House and Senate, and fail to generate bipartisan support.

Modernizing Medicaid Managed Care: Can States Meet the Data Challenges?

The expansion of the Medicaid program under the Affordable Care Act (ACA) is one of the most consequential andcontroversialchangesinthehistoryofUShealthpolicy. During the struggle over ACA implementation, attention has largely focused on partisan disagreements about whether states should expand Medicaid coverage. The states have also been the site of a quieter struggle to modernize Medicaid’s managed care programs, in which many new Medicaid beneficiaries will be required to enroll. A central issue in state modernization efforts involves data collection. On June 1, 2015, the Centers for Medicare & Medicaid Services (CMS) proposed a long-overdue overhaul of Medicaid managed care that, among other provisions, will implement ACA requirements for states to collect a standard set of encounter data—detailed records of services delivered to beneficiaries—from Medicaid managed care organizations (MCOs). Encounter data are the only way to know whether the majority of Medicaid enrollees are receiving the care they need, that the care is of adequate quality, and that it is delivered at the lowest possible cost. These data are especially important because Medicaid covers 70 million people, including a large share of vulnerable populations (approximately 37% of children and 46% of pregnant women) in the United States and has an average annual cost of

Paths to (de)centralization: Changing territorial dynamics of social policy in the People’s Republic of China and the United States

475 billion to federal and state taxpayers.1 Approximately 74% of Medicaid enrollees are enrolled in MCOs, with mandatory enrollment in many states; however, standardized encounter data are largely unavailable for the populations served by these programs.2 Although the proposed rule could be finalized as early as 2016, many challenges remain for its implementation. States have been slow to adapt their data collection systems to the growth of managed care. According to a July 2015 report by the Office of Inspector General, 11 of 21 states with comprehensive managed care programs did not report encounter data from all managed care entities, and 8 states did not report any encounter data to CMS by the required deadline.3 In states like Illinois, no managed care entities report encounter data files involving long-term care or prescription drugs, leaving major gaps in what is known about the quality of care in these programs.3 Gaps in federal regulations have allowed this situation to persist. CMS currently allows states to define the types of MCO encounter data they will provide and imposes no penalties on states or MCOs that do not submit these data (Table). This is in stark contrast to what has been required of Medicare Advantage plans since 2008—plans that enroll a smaller share of beneficiaries on a voluntary basis. Medicare Advantage plan sponsors must report encounter data for a variety of elements specified by CMS, including diagnoses, as well as the amounts charged and paid for services. The proposed rule would effectively harmonize the requirements between Medicare and Medicaid managed care by requiring states and MCOs to submit a standard set of encounter data. Although the rule only hints at a full list of minimum data elements, it makes clear that states that do not comply with new data submission requirements will lose federal matching payments. Collecting a standard set of encounter data from MCOs will allow Medicaid programs to better serve their historical role as health policy laboratories, learning and experimenting with reforms to improve health care access, quality, and affordability. For example, analyses of detailed data from fee-for-service Medicare have shown that Medicare payments per beneficiary vary from approximately

From metaphors to measures: observable indicators of gradual institutional change – CORRIGENDUM

5000 in some regions to more than

Reassessing Policy Drift: Social Policy Change in the United States

13 000 in others with no added benefit in life expectancy or quality of care.6,7 Standardized encounter data also could be used in comparative effectiveness research. Given the important role of Medicaid in covering vulnerable populations in the United States, data on diagnoses, procedures, and measures of utilization would fill substantial gaps in current understanding of how best to treat these groups. Nevertheless, meeting the challenges set out by the proposed regulations will not be easy. Historically, state data-collection efforts have encountered political obstacles.Forexample,manyMCOsconsiderencounterdata on payments to clinicians and health care entities to be proprietary and are concerned that data release presents an opportunity for competitors to gain access to this information. In some cases, MCOs also may lack the resources for frequent and high-quality data submissions. Without access to payment data, however, it is not possible to determine how increases or decreases in Medicaid managed care plans’ reimbursement policies affect the quality and accessibility of care. States also have to address the technical complexity in developing systems to collect and validate the data. In states with limited resources and technical capacity, Medicaid staff have insufficient time to learn the nuances of encounter datacollection systems. MCOs also report that communication difficulties with state agencies make it difficult to comply with rapid changes in new uniform data requirements or new systems for data submission, especially when data must be submitted to multiple agencies.8 None of these challenges is insurmountable, however, if CMS and the states leverage their capacity to enhance existing data systems. Significantly, the new regulations only emerged after a period of 5 years in which CMS developed and disseminated valuable information about the challenges of, and solutions to, modernizing state Medicaid data systems. In the last 2 years, CMS VIEWPOINT

Obamacare Wars: Federalism, State Politics, and the Affordable Care Act

Drawing on the existing welfare state literature, this article offers a comparative analytical framework to account for the territorial dynamics of social policy in the United States and the People’s Republic of China, two countries that are most dissimilar in terms of political regime but that may exhibit similar territorial patterns of social policy fragmentation. A promising way to explore such patterns, we argue, is to analyze how changes in the architecture of major governing institutions affect the territorial dimension of social policy. In the United States, state governments and a territorially-organized federal legislature have increasingly accommodated national political parties. These two parties have turned the politics of social policy into a debate over the boundaries of national or state governance of social policy, resulting in multi-level governance frameworks. In the People’s Republic of China, the partisan dimension is absent, but strong economic pressures on the central bureaucracy have made devolution a functional imperative and have given local governments increasing leverage when bargaining with the center.