State discretion and medicaid program variation in long-term care: when is enough, enough?

The effect of political control on financial performance, structure, and outcomes of US nursing homes

Objective

To evaluate the effect of partisan political control on financial performance, structure, and outcomes of for‐profit and not‐for‐profit US nursing homes.

Data Sources/Study Setting

Nineteen‐year panel (1996‐2014) of state election outcomes, financial performance data from nursing home cost reports, operational and aggregate resident characteristics from OSCAR of 13 737 nursing homes.

Study Design

A linear panel model was estimated to identify the effect of Democratic and Republican political control on next year's outcomes. Nursing home outcomes were defined as yearly facility revenues, expenses, and profits; the number of Medicaid, Medicare, and private‐pay residents; staffing levels; and selected resident outcomes.

Principal Findings

Democratic political control leads to an increase in financial flows to for‐profit nursing homes, boosting profits without producing observable improvements in resident outcomes. Republican political control leads to lower revenues and profits of for‐profit nursing homes. A shift from Medicaid to more profitable private‐pay residents following Republican political control is observed for all nursing homes. Financial performance of not‐for‐profit nursing homes is not significantly affected by changes in political control.

Conclusion

Political control of the two legislative chambers—but not of the governorship—shapes the structure of the nursing home industry as seen in provider behavior.

Mobile Citizens: Medicaid Home and Community-Based Services Users Desire and Pursue Cross-State Moves

This article provides empirical evidence that Medicaid home and community-based services (HCBS) users with physical disabilities both express desire for, and engage in steps to, move across states, driven primarily by opportunity. These opportunities include employment, schooling, and proximity to social support. Grounded theory techniques were used to explore transcripts from interviews with 18 HCBS users with physical disabilities. Findings are presented as a series of trajectories that connect opportunity with plans for, or action taken to engage in, cross-state moves. The move stories offered by participants illustrate that for Medicaid HCBS users with physical disabilities, opportunity may be dreamed, missed, delayed, or pursued. Stories depicting each of these four opportunity arcs are provided. The article concludes with a discussion of the importance of recognizing the agency of Medicaid HCBS users as they wish to pursue opportunities across states, as well as the structural barriers presented by interstate variation and intrastate confinement. Suggestions are offered to advance research, policy, and practice to honor the dignity and self-determination of Medicaid HCBS users with physical disabilities as they consider opportunities across states.

The Politics of Medicaid: Most Americans Are Connected to the Program, Support Its Expansion, and Do Not View It as Stigmatizing

Policy Points: More than half of Americans are connected to the Medicaid program-either through their own coverage or that of a family member or close friend-and are significantly more likely to view Medicaid as important and to support increases in spending, even among conservatives. This finding helps explain why Affordable Care Act repeal efforts faced (and will continue to face) strong public backlash. Policymakers should be aware that although renaming programs within Medicaid may have increased enrollment take-up, this destigmatization effort might have also increased program confusion and reduced support for Medicaid even among enrollees who say the program is important to them.

CONTEXT

Since the 1980s, Medicaid enrollment has expanded so dramatically that by 2015 two-thirds of Americans had some connection to the program in which either they themselves, a family member, or a close friend is currently or was previously enrolled.

METHODS

Utilizing a nationally representative survey-the Kaiser Family Foundation Poll: Medicare and Medicaid at 50 (n = 1,849)-and employing ordinal and logistic regression analyses, our study examines 3 questions: (1) are individuals with a connection to Medicaid more likely to view the program as important, (2) are they more likely to support an increase in Medicaid spending, and (3) are they more likely to support adoption of the Medicaid expansion offered under the Affordable Care Act? For each of these questions we examine whether partisanship and views of stigma also impact support for Medicaid and, if so, whether these factors overwhelm the impact of connection to the program.

FINDINGS

Controlling for the strong effect of partisanship, people with any connection to the Medicaid program are more likely to view the program as important than those with no connection. However, when it comes to increasing spending or expanding the program, the type of connection to the program matters. In particular, adults with current and previous Medicaid coverage and those with a family member or close friend with Medicaid coverage are more likely to support increases in spending and the Medicaid expansion; but, those connected to Medicaid only through coverage of a child are no more likely to support Medicaid than those with no connection.

CONCLUSIONS

Future research should probe more deeply into whether people with different types of connection to Medicaid view the program differently, and, if so, how and why. Moreover, future research should also explore whether state-level attempts to destigmatize Medicaid by renaming the program also serves to reduce knowledge and support for Medicaid.

Practice variation in the Dutch long-term care and the role of supply-sensitive care: Is access to the Dutch long-term care equitable?

Universal access and generous coverage are important goals of the Dutch long-term care (LTC) system. It is a legal requirement that everyone eligible for LTC should be able to receive it. Institutional care (IC) made up for 90% of Dutch LTC spending. To investigate whether access to IC is as equitable as the Dutch government aspires, we explored practice variation in entitlements to IC across Dutch regions. We used a unique dataset that included all individual applications for Dutch LTC in January 2010-December 2013 (N = 3,373,358). This dataset enabled an accurate identification of the need for care. We examined the local variation in the probability of being granted long-term IC and in the intensity of the care granted given that individuals have applied for LTC. We also investigated whether the variation observed was related to differences in the local availability of care facilities. Although our analyses indicated the presence of some practice variation, its magnitude was very small by national and international standards (up to 3%). Only a minor part of the practice variation could be accounted for by local supply differences in care facilities. Overall, we conclude that, unlike many other developed countries, the Dutch system ensured equitable access to long-term IC.

Bureaucratic Policy Making on Trial: Medicaid Nursing Facility Reimbursement, 1988-1998

Few systematically assess the determinants of Medicaid nursing facility reimbursement. Consequently, this article examines what factors influenceprogram administrators’decisions regarding nursing facility cost report data—the basic information states use to establish payment. Whereas elected officials focus primarily on how much is spent on nursing homes, state Medicaid officials assume primary responsibility for the esoteric and highly technical dimensions that help make spending goals a reality. Findings indicate that the federal government influenced state policy by enabling provider litigation under the Boren Amendment. They also indicate that program administrators responded rationally to fiscal and economic concerns, and that states with stronger administrative capacity were better able to overcome obstacles to sustaining desired policies. Although results reveal that states with more powerful nursing home lobbies tended to implement more generous systems, they fail to reveal significant associations between cost report year and lobbying activity on behalf of the elderly.

Medicaid Long-Term Care: State Variation and the Intergovernmental Lobby

Medicaid is vastly more important than Medicare or private insurance in funding long-term care (LTC). However, states vary tremendously in their commitment to Medicaid LTC. This article advances knowledge of the origins, nature, and implications of this variation. After examining the degree of variation in state spending on Medicaid LTC, we show how federal policy has over the past fifty years steadily increased state discretion to shape these services. This decentralization largely reflects the potency of the intergovernmental lobby-governors and other state officials-in influencing federal policy. While fueling state variation, the intergovernmental lobby has also provided valuable political support that has helped Medicaid grow and resist retrenchment. After considering policy options that could mitigate Medicaid LTC inequities rooted in state differences, we assess how the catalytic forces that have fueled growth in Medicaid LTC may be insufficient to protect the program from future erosion.

The role of the media in agenda setting: the case of long-term care rebalancing

This study investigates the role of print media in state policy agendas in four states-Connecticut, Minnesota, Oregon, and Utah-in rebalancing long-term care away from institutions toward home- and community-based (HCBS) services. Ordinary least squares regression is used to model states' policy agendas, as measured by the proportion of Medicaid long-term care spending on HCBS expenditures and number of rebalancing bills proposed, from 1999 to 2008. Results reveal a relationship between states' rebalancing agendas and the extent of media coverage, and state economic, political, and programmatic characteristics. Findings suggest that media coverage reflects broader shifts in state-level attitudes toward rebalancing.

Maximizing federal Medicaid dollars: nursing home provider tax adoption, 2000-2004

Since Medicaid is jointly financed by the federal and state governments, state officials have sought to offset state expenditures by maximizing federal contributions. One such strategy is to adopt a provider tax, which enables states to collect revenues from providers; those revenues are then used to pay for services rendered to Medicaid recipients, thereby leveraging federal matching dollars without concomitant increases in state expenditures. The number of states adopting a nursing home tax increased from thirteen to thirty-one between 2000 and 2004. This study seeks to identify the factors that spurred the rapid increase in nursing home provider taxes following implementation of the Balanced Budget Act of 1997. Results indicate that states with more powerful nursing home lobbies, lower proportions of private pay nursing home residents, worse fiscal health, weaker fiscal capacity, broader Medicaid eligibility, and nursing home supply restrictions were more likely to adopt. This implies that state officials react rationally to prevailing fiscal and programmatic circumstances when formulating policy under Medicaid and that providers seek relief, in part, from the adverse fiscal consequences of federal policy changes by promoting policy change at the state level.

Meeting the demographic challenges ahead: Toward culture change in an ageing New Zealand

There are several innovative service delivery models in the United States (US) relevant to long-term care policy development and implementation in New Zealand. An especially fruitful source of innovation has been the culture change movement, which originated in the US but has begun to spread to New Zealand and other OECD countries. The culture change philosophy requires that providers respond to the values, preferences, and needs of care recipients. It also requires devolving authority to direct care workers who know their clients best, in addition to transitioning from sterile 'clinical' settings to more homelike environments. New Zealand has a more favourable policy context for improving long-term care than the US. Thus, it is critical that it build upon these short term advantages to promote further dissemination of the culture change ethos, thereby placing caregivers in a better position to meet current care challenges, not to mention those posed by growth in the elderly population ahead.

Medicaid nursing facility reimbursement in flux: effects of federal regulatory changes and prevailing fiscal conditions, 1978-1998

Basic concepts and trends are examined in Medicaid nursing facility reimbursements between 1978 and 1998, because Medicaid payment reform is a common budget reduction strategy pursued by state officials. Non-incremental changes in state rate-setting methods, as well as incremental changes in per diem rates and expenditures per recipient, are analyzed. In addition to substantial cross-state variation, results reveal clear trends in reimbursement policy characteristics over time. Not only do these track closely with changes in the federal regulatory environment, but they also track closely with prevailing fiscal and economic conditions. Given the serious ramifications reimbursement policy changes can have for nursing home residents and providers, it is imperative that the impact of federal disengagement from this policy area be understood.