Medicaid State Plan Personal Care Services

Abstract

Policymakers face mounting pressures from consumer demand and the 1999 Olmstead Supreme Court decision to extend formal (paid) programs that deliver personal care to the elderly, chronically ill, and disabled. Despite this, very little is known about the largest program that delivers personal care: the Medicaid State Plan personal care services (PCS) optional benefit. This paper presents the latest available national program (participant and expenditure) trend data (1999–2002) on the Medicaid PCS benefit and findings from a national survey of eligibility and cost control policies in use on the program. The program trends show that, over the study period, the number of states providing the Medicaid PCS benefit grew by four (from 26 to 30), and national program participation, adjusted for population growth, increased by 27%. However, inflation-adjusted program expenditures per participant declined by 3% between 1999 and 2002. Findings from the policy survey reveal that between 1999 and 2002 there was a marked decline in the range of services provided, and by 2004, almost half the programs operated a cap on the hours of services provided.     

Potential Consequences of Raising the Social Security Eligibility Age on Low-Income Older Workers

Abstract

To examine the potential consequences of raising the Social Security retirement age on future cohorts of low-income elders, this study, based on data from the Health and Retirement Study, 1992–1994, identifies factors that may hinder or facilitate continuous employment among older workers born between 1931 and 1941. Specifically, following the analysis of labor-force participation rates and self-reported reasons for non-work, multivariate logistic regression models tested the relationship between individual strengths and constraints, social-structural opportunities and constraints, and economic need variables and the likelihood of work. The findings show that for both men and women, having disabilities was the most significant predictor of non-work. Racial differences, especially in men's labor-force participation rates, appeared to be due in large part to significant racial differences in disability rates. A higher proportion of blacks and Hispanics than whites also reported that they were unemployed. Based on the findings, raising the Social Security eligibility age is likely to result in increased numbers of Disability Insurance (DI) claimants, and the fiscal impact of such an increase needs to be examined. The need to assist unemployed older persons is also discussed.     

State Discretion and Medicaid Program Variation in Long-Term Care

Summary

Although federal statutes and regulations establish the broad parameters within which state Medicaid programs operate, the federal government grants states substantial discretion over Medicaid and Medicaid-funded long-term care. An appreciation of resulting cross-state variation in Medicaid program characteristics, however, has been lacking in the ongoing debate over whether the federal government should further devolve responsibility for caring for the poor and disabled elderly to the states. To better inform this discussion, therefore, this article documents considerable variation, not only in terms of Medicaid program spending and recipients, but also in terms of strategies chosen to reform long-term care services and financing. Since there is little doubt that states take full advantage of current levels of discretion, advocates of devolution may want to reassess their views to consider whether existing variation has resulted in inequities addressable only through more, not less, federal involvement.     

Medicare and Medicaid Reimbursement Rates for Nursing Homes Motivate Select Culture Change Practices But Not Comprehensive Culture Change

Components of nursing home (NH) culture change include resident-centeredness, empowerment, and home likeness, but practices reflective of these components may be found in both traditional and “culture change” NHs. We use mixed methods to examine the presence of culture change practices in the context of an NH’s payer sources. Qualitative data show how higher pay from Medicare versus Medicaid influences implementation of select culture change practices, and quantitative data show NHs with higher proportions of Medicare residents have significantly higher (measured) environmental culture change implementation. Findings indicate that heightened coordination of Medicare and Medicaid could influence NH implementation of reform practices.     

Comparing States' Medicaid Nursing Facilities and Home and Community-Based Services Long-Term Care Programs: Quality and Fit with Inclination,Capacity, and Need

States employ home and community-based services (HCBS) increasingly in Medicaid support of long-term care and rely less on nursing facilities. We examine how states' nursing facilities and HCBS programs compare and whether states' long-term care responses match their ideological inclination toward, material capacity for supporting, and their citizens' need for these public social programs. We use cross-sectional panel data on structural, process, and outcome quality for nursing facilities and HCBS congregate residential programs. We rank states, correlate these measures, and use regression to link inclination, capacity, and need to quality. We find that states' nursing facility and HCBS program quality are not closely related and that state HCBS congregate residential program quality is independent of inclination, capacity, and need. This latter result underscores a need for uniform HCBS standards and better data on quality.     

Medicaid Home and Community-Based Services: How Consumer Access Is Restricted by State Policies

State Medicaid programs have expanded home and community-based services (HCBS). This article compares trends and variations in state policies for Medicaid HCBS programs in 2005 and 2010. State limitations on financial eligibility criteria and service benefits have remained stable. Although the use of consumer direction, independent providers, and family care providers has increased, some states do not have these options. The increased adoption of state cost control policies have led to large increases in persons on waiver wait lists. Access could be improved by standardizing and liberalizing state HCBS policies, but state fiscal concerns are barriers to rebalancing between HCBS and institutional services.     

Medicaid physician fees and the quality of medical care of Medicaid patients in the USA

When enacted in 1965, the original Medicaid legislation sought to finance access to mainstream medical care for the poor. I use data on visits to office-based physicians from the National Ambulatory Medical Care Survey in four years—1989, 1993, 1998 and 2003—to test the extent to which this goal has been achieved. Specifically, I test whether this goal has been achieved more in states that pay higher fees to physicians who treat Medicaid patients compared to states that pay lower fees. By comparing the treatment of Medicaid patients to that of privately-insured patients and by using state fixed effects, I am able to estimate the effects of changes in the generosity of Medicaid physician payment within a state on changes in access to care for Medicaid patients, therefore separating Medicaid’s effect on access to health care from any correlation between the Medicaid fee and other attributes of the state in which a patient lives. Using this method, I examine the effect of Medicaid fees on whether or not an office-based physician accepts Medicaid patients, on the fraction of a physician’s practice that is accounted for by Medicaid, and on the length of visit times with physicians. Results imply that higher Medicaid fees increase the number of private physicians, especially in medical and surgical specialties, who see Medicaid patients. Higher fees also lead to visit times with physicians that are more comparable to visit times with private pay patients.

Beneficiary Work: The Hidden Labor of Medicaid Users Pursuing Cross-State Moves

For users of Medicaid personal care assistance (PCA) services and their families, interstate variation in eligibility and service availability act as structural barriers to cross-state movement. However, program users desire and pursue cross-state moves. In this article, we provide a grounded theory analysis of 18 interviews with Medicaid PCA users with physical disabilities who expressed desire for or pursued cross-state moves. Our analysis identified six forms of previously unnamed and unrecognized work. As PCA users plan or pursue cross-state moves, they are also (1) assessing service ecosystems, (2) finding the right door, (3) persisting through the bureaucratic gauntlet, (4) advocating for systems cooperation, (5) reestablishing networks of support, and (6) responding to service gaps/lapses. Collectively, we describe this hidden labor as beneficiary work, the unremunerated work that program users must do in order to retain access to benefits for which they qualify. Beneficiary work, while hidden, is not optional; it is necessary for continued access to community and broadly, for survival. Identifying and describing beneficiary work expands on Feminist and interactionist perspectives on disability, poverty, and work, and highlights the need for changes to Medicaid policy that address PCA users as mobile citizens.     

An Examination of the Woodwork Effect Using National Medicaid Long-Term Services and Supports Data

A common concern in long-term services and supports (LTSS) policy is the “woodwork effect,” which has two components: (1) more people will use publicly funded services if access to home- and community-based services (HCBS) is expanded; and (2) the additional beneficiaries will increase the growth rate of LTSS expenditures. Medicaid LTSS beneficiary and utilization data starting in 1999 indicate modest growth in beneficiaries and expenditures, after adjusting for inflation and the number of people with functional impairments. The data do not provide strong evidence that the shift in Medicaid funding toward HCBS significantly increased or decreased overall Medicaid LTSS spending.     

高职院校焊接专业招生难的原因及对策

高职院校焊接专业招生难度大已成为不争的事实,成为制约焊接技术应用型人才培养的瓶颈。在审视高职院校焊接专业招生难现象的基础上,分析了招生难的原因,探讨了解决招生难的对策。     

Estimating the Expense of a Mandatory Home- and Community-Based Personal Assistance Services Benefit Under Medicaid

Abstract

Personal assistance services (PAS) are essential for many people of all ages with significant disabilities, but these services are not always available to individuals at home or in the community, in large part due to a significant bias toward institutions in the Medicaid program. This study aims to provide an estimate of the expense of a mandatory personal assistance services (PAS) benefit under Medicaid for persons with low incomes, low assets, and significant disability.

Design and methods: We use year 2003 data from the Survey of Income and Program Participation to estimate the number of people living in households who would be eligible, based on having an institutional level of need and meeting financial criteria for low income and low assets, combined with additional survey data on annual expenditures under Medicaid programs providing PAS.

Results: New expenditures for PAS are estimated to be $1.4–$3.7 billion per year (in 2006 dollars), depending on the rate of participation, for up to half a million new recipients, more than a third of whom would be ages 65 and older. These estimated expenditures are a tenth of those estimated by the Congressional Budget Office for implementing the Medicaid Community-Based Attendant Services and Supports Act (MiCASSA).

Implications: Creating a mandatory PAS benefit for those with an institutional level of need is a fiscally achievable policy strategy to redress the imbalance between institutional and community-based services under Medicaid.     

河北省生源地助学贷款需求、供给与还款分析——以河北农业大学为例

：生源地助学贷款具有承贷主体多元化、放款形式多样化、贷款管理属地化等优势,作为国家助学贷款的有益补充具有广阔的发展前景。根据对河北农业大学生源地助学贷款在校生和毕业生的问卷调查和数据分析,在需求和供给方面存在着供给量不足、供给形式单一等问题;在还款方面,存在着还款期限短、违约率较高等问题。针对上述问题,应通过加大政策扶持力度、建立风险基金和信用体系等措施来解决,以促进河北省生源地助学贷款的健康发展。     

Implementing Evidence‐Based Parenting Programmes in a Small Sample of English Urban Local Authorities: Eligibility,Fidelity and Intensity

This article focuses on the implementation of evidence‐based parenting programmes (EBPPs) in a small sample of urban local authorities in England. The first part discusses the development of government policy, guidance and implementation issues. The second part presents findings from an exploratory study, which focused on the implementation of EBPPs in terms of programme eligibility, fidelity and intensity in six urban local authorities. Implementation was not necessarily in line with policy or guidance. Issues associated with programme fidelity along with concerns about sustainability as a result of cuts in funding are discussed and implications for policy and future research considered.     

Florida's Efforts to Improve Quality of Nursing Home Care Through Nurse Staffing Standards,Regulation, and Medicaid Reimbursement

Between 1999 and 2007, Florida implemented two initiatives combining legislative, regulatory, and reimbursement strategies to increase nurse staffing levels in nursing homes to improve quality of care. Despite a $40 million incentive package allocated for direct-care staffing, per-resident-day staffing increased only after legislative requirements mandated minimum nursing hours per resident day. Total Medicaid expenditures grew by $1.1 billion over the 8 years; per diem rates increased 65% to reimburse providers' costs. Registered nurses' hours decreased, while licensed nurses' and paraprofessionals' hours increased. This article describes the impact of staffing policy changes, includes stakeholders' views about approaches to achieve quality outcomes, and documents state policy implementation efforts. Seven lessons from the implementation of state nurse staffing standards to improve quality of care outcomes are also presented.     

Distribution and Utilization of Home- and Community-Based Long-Term Care Services for the Elderly in North Carolina

ABSTRACT

Provision of home- and community-based long-term care is a growing concern at the national, state, and local levels. As more persons grow old, the need for these services is expected to rise. This analysis examines the distribution and utilization of three home- and community-based long-term care programs in North Carolina for each of the state's 100 counties. Maps were generated to examine how counties differed in respect to service utilization among the elderly. Great variability was found in number of elderly utilizing the services across the state as well as the percent of Medicaid- and/or age-eligible persons who utilized the programs. Multivariate modeling for associations to service utilization was only possible for one of the long-term care programs. Results indicated that living alone, being non-white, and having a mobility and self-care limitation were all positively related to utilization. Percent of persons 85 years or older and the ratio of institutionalized long-term care beds were negatively associated with utilization. It was concluded that states must engage in concerted efforts to ensure equity in access to home- and community-based long-term care.     

DPR Debate: Growth Identification and Facilitation: The Role of the State in the Dynamics of Structural Change

This DPR Debate is based on the contribution by Justin Lin, Chief Economist at the World Bank, and his colleague Célestin Monga, on ‘Growth Identification and Facilitation: The Role of the State in the Dynamics of Structural Change’. The article under consideration is important and timely as it articulates a number of new policy implications from Justin Lin's earlier work on New Structural Economics, which was discussed in a previous DPR debate (Lin and Chang, 2009). This symposium contains the article and comments on it from five distinguished specialists, and closes with a rejoinder by Lin and Monga. This introduction discusses the article, the comments and the rejoinder. The historical record indicates that, in all successful economies, the state has always played an important role in facilitating structural change and helping the private sector sustain it across time. This article puts forward a new approach to help policy‐makers in developing countries identify those industries that may hold latent comparative advantage, and recommends ways of removing binding constraints to facilitate private firms' entry into those industries. Two types of government interventions are distinguished: first, policies that facilitate structural change by overcoming information, co‐ordination and externality issues, which are intrinsic to industrial upgrading and diversification; and second, policies aimed at protecting certain selected firms and industries that defy the comparative advantage determined by the existing endowment structure.     

The regulatory breadth index: A new tool for the measurement and comparison of state-level charity regulation in the United States

The bulk of charity regulation in the United States occurs at the state level, yet state-level charity regulation remains relatively under-researched within nonprofit scholarship, particularly from a comparative perspective. The complexity and variation in statutory regulation, coupled with the large volume of legal research required to study state-level charity regulation systematically, has impeded scholarly progress toward a better understanding of the US charitable sector. We address this problem by deriving a state-level charity regulatory breadth index (RBI) that will enable nonprofit researchers to contextualize state-level charity research within a broader framework and to incorporate state-level regulation into analyses across states. Policymakers can also benefit from the ability to benchmark their regulatory regimes against their peers.     

Disability-policy models in European welfare regimes: comparing the distribution of social protection,labour-market integration and civil rights

This paper examines different models of disability policy in European welfare regimes on the basis of secondary data. OECD data measuring social protection and labour-market integration is complemented with an index which measures the outcomes of disability civil rights. Eurobarometer data is used to construct the index. The country modelling by cluster analysis indicates that an encompassing model of disability policy is mainly prevalent in Nordic countries. An activating and rehabilitating disability-policy model is predominant mainly in Central European countries, and there is evidence for a distinct Eastern European model characterized by relatively few guaranteed civil rights for disabled people. Furthermore, the Southern European model, which indicates a preference for social protection rather than activation and rehabilitation, includes countries which normally have diverse welfare traditions.     

With/Out a State,Kurds Rising: The Un/Stated Foreign Policy and the Rise of the Kurdish Regional Government in Iraq

Abstract

Located in northern Iraq, the Kurdistan Regional Government (KRG) rules over an autonomous province in Iraq. Constitutionally, ‘Kurdistan Region’ is not independent, but empirically the KRG behaves as if it is a sovereign entity. With an elected parliament, a president, a prime minister, a cabinet, a flag, a national anthem, schools taught in Kurdish, and a booming economy, the ‘Kurdistan’ embodied by the KRG clearly exists empirically while unrecognized internationally. In this paper, I examine the rise of the KRG as an agent in international relations since the first Gulf War in 1991. I argue that foreign policy as a field of conduct and discourse has been central to the KRG's effective agency. In my analysis, I employ and interrelate Robert Jackson's work on ‘quasi-states’, Doug McAdam's argument on ‘political opportunity structures', and Giorgio Agamben's discussion on ‘indistinct zones of politics’ as in Iraq and the Middle East. Ultimately, I contend that while less than a full state in constitutional legal form, the KRG is more than a quasi-state in substance.¹1 See the official site of KRG at: http://cabinet.gov.krd/?l=12