Health care innovations for homeless families: Emerging opportunities under Medicaid and the Affordable Care Act

Prior to the Patient Protection and Affordable Care Act of 2010 (the ACA), the US health care system left many low-income families facing limited access to medical care, struggling with high-health costs, or lacking health insurance altogether. The ACA aims to increase access to care, improve the quality of care, and lower total health care costs. While the ACA can benefit all individuals and families, it has significant potential for expanding and improving services for those experiencing homelessness. This paper describes specific opportunities under the ACA and Medicaid that can be used to strengthen services for homeless families and provides examples of efforts under way. It also offers guidance for how homeless service agencies can effect change in their respective states. The examples described here are promising approaches to strengthening homeless services. Pursuing these ideas for homeless families will require initiative, creativity, and perseverance, but recent progress is encouraging.     

Change and Inertia in the New York State Medicaid Personal Care Services Program: An Institutional Case Study

This study analyzes how competing logics (belief systems) of stakeholders have influenced patterns of change and inertia in the development of the New York Medicaid Personal Care Services (PCS) program. A case-study methodology was used to collect documents, statistics, and interview data from four key stakeholder groups: state and city officials, PCS agencies, a labor union, and consumer advocates covering the period 1999 to 2005. The New York PCS program is one of the oldest, largest, and most stable programs in the United States. Its early unionization of workers resulted in relatively generous wages and benefits and made New York number one nationally in PCS spending per capita. In spite of wide support from stakeholder groups, the overall number of participants has gradually declined since 1999. A consumer-directed model of personal care developed in 1995 challenged the status quo and has grown steadily. Resistance by public officials, agency providers, and union representatives to the consumer-directed model has resulted in a small program that is often targeted toward individuals labeled “difficult to serve.” Dominant stakeholders in New York have ensured a stable personal care program that has resisted change and led to program inertia.     

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.     

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.     

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.     

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.     

Effects of Medicaid managed care policies on mental health service use among a national probability sample of children in the child welfare system

Children in the child welfare system are dependent upon Medicaid to finance services for their considerable mental health needs. This study examines the effects of Medicaid policies on mental health service use among a national probability sample of children in the child welfare system. Data for this study came from the National Survey of Child and Adolescent Well-Being, the Caring for Children in Child Welfare study, and the Area Resource File. Weighted multivariate logistic regression analyses were conducted to estimate effects of policy variables on children's use of mental health services, controlling for child-level covariates and county-level health resources. Children in counties with behavioral carve-outs under Medicaid managed care had lower odds of inpatient mental health service use. Medicaid managed care enrollment and variations in type of provider reimbursement did not affect use of mental health services. Older age, greater need for mental health services, and higher levels of caregiver education were associated with increased odds of service use. Restrictions on use of inpatient mental healthcare caused by behavioral carve-outs may disproportionately affect children in the child welfare system who have high rates of such use. Careful adoption of carve-outs is necessary to assure appropriate care for these children.     

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.     

Restrictiveness of Eligibility Determination and Medicaid Enrollment by Low-Income Seniors

Medicaid is an important source of supplemental health care coverage for low-income seniors, yet little is known about the effect of state policy on Medicaid enrollment by eligible elderly. Data from a nationally representative survey were used to examine Medicaid enrollment by elderly, low-income Medicare beneficiaries living in states that liberalize or restrict Medicaid eligibility criteria using the 1986 Omnibus Budget Reconciliation Act or provision 209(b) of the 1972 Social Security Act Amendment, respectively. Controlling for demographics and health status, residence in states applying these laws was significantly, though modestly, associated with Medicaid enrollment. Additionally, 73% of eligible elderly Medicare beneficiaries were not enrolled in Medicaid, and most have serious chronic health problems. These findings suggest that a significant number of eligible elderly are not enrolled in Medicaid and that liberalizing or tightening Medicaid eligibility criteria can have an impact on Medicaid enrollment by low-income elderly patients.     

Maternal child care preferences for infants,toddlers, and preschoolers: the disconnect between policy and preference in the USA

While much research exists looking at parental preferences for child care, much of that research uses child care choice as a proxy for preference. In an effort to examine the types of care mothers prefer if no constraints were placed on their decision, this quantitative study investigated how family demographic factors and family role ideology relate to the types of child care (parental and non-parental forms) mothers prefer ‘in an ideal world’ using a sample of 345 employed mothers of children under 6 years of age in a suburb of a large metropolitan area in the southern USA. Participants completed a questionnaire examining the types of care they viewed as ideal for infants (0–12 months old), toddlers (13–30 months old), and preschoolers (31–72 months old) if no constraints were placed on the decision. Results indicated that the preferences for type of care for mothers in this sample varied according to the child's age, with a large majority of mothers preferring parental care for their children. Ideological and demographic factors predicting preferences for first and second choice of child care were also explored through binary and multinomial logistic regression, revealing the influence of ethnicity, education, and family role ideology to preferences for infant care. These results add to the existing literature by confirming previous findings about the influence of child age to child care preferences, as well as highlighting the disconnect between these preferences and the way family policies are structured in the USA.     

Child care quality and affordability: Are they compatible?

Mothers have traditionally been the primary caregivers of children under school age in the United States. Increasing numbers of parents are seeking part-time or full-time alternatives for assistance with parenting and child care outside of the home. The variety of types of child care arrangements has greatly increased in the past 50 years. This paper addresses quality child care, child care options and cost. Despite the increase in child care provided outside the home, parents often have difficulty distinguishing quality care from less than quality care. Two prime considerations are quality and affordability. This paper addresses the need for a comprehensive spectrum of policies and child care programs for families in various cultural, economic, and social environments.     

Self-Stigma of seeking help and job burnout in mental health care providers: the comparative study of Lithuanian and the USA samples

This study aimed to explore the correlation between job burnout and self-stigma of seeking help among nonmedical mental health care providers (psychologists, social workers, and counselors) in two countries – Lithuania and the US. The study included 234 professionals (111 social workers and 123 psychologists) from Lithuania and 93 professionals (33 counselors, 23 social workers, and 37 psychologists) from the US on a voluntary basis (93% females, mean age – 39.81?years). They completed a self-reported questionnaire with the Self-Stigma of Seeking Help Scale (SSOSH) and the Maslach Burnout Inventory-General Survey (MBI-GS). The results revealed a statistically significant positive correlation between self-stigmatization and burnout in the Lithuanian sample, but only weak positive correlation between depersonalization and self-stigma of seeking help in the US sample. The relationship between the self-stigma of seeking help and burnout was stronger in the Lithuanian sample of professionals when compared to their colleagues in the US.     

The Woodwork Effect in Medicaid Long-Term Services and Supports

This paper examines annual real per capita Medicaid long-term services and supports (LTSS) expenditures (in 2010 $) over the period 1995 to 2010. Medicaid community LTSS expenditures increased substantially. If that trend constituted a woodwork effect, expenditures on institutional services should have declined more slowly than community expenditures increased, resulting in total expenditures increasing over time. Such a woodwork effect is observed for the population with intellectual and developmental disabilities (IDD) but not for the non-IDD population, composed of persons with disabilities other than IDD, including older persons. During this time period, the goals for serving people with IDD changed; institutional and community cost-neutrality rules were relaxed (and with that concerns over a woodwork effect), and instead goals of community involvement and participation were emphasized for all eligible persons. For the non-IDD population, tighter adherence to cost-neutrality rules and controls over nursing home reimbursements may have helped avoid a woodwork effect as community expenditures increased. With the passage of the Americans with Disabilities Act in 1990, goals have changed for people with disabilities of all ages, and the notion of a simple trade-off between institutional and community service costs that constitutes the woodwork effect must be complemented with a much broader idea of cost analysis that values independence and community participation for people with disabilities of all ages.     

Therapeutic alliance between youth and staff in residential group care: Psychometrics of the therapeutic alliance quality scale

Therapeutic alliance has been frequently studied in individual counseling sessions; however, research on therapeutic alliance in residential settings for youth with mental health diagnoses has been limited. This may be due, in part, to the presence of multiple service providers often in caregiving roles. The purpose of this study was to examine the psychometric quality of a widely utilized measure of therapeutic alliance used in psychotherapy with youth in residential care where the treatment is provided by a trained married couple. We also compared the relationship between youth ratings of their male and female service providers, as well as examined correlations in ratings between youth and staff on therapeutic alliance. Finally, we investigated the direction, magnitude, and trajectory of change in therapeutic alliance over a 12-month period following admission into residential care. The method was a longitudinal assessment of 135 youth and 124 staff regarding therapeutic alliance over the course of 12 months or discharge from services. Results indicated strong psychometric properties and high correlations for youth ratings of both their male and female service providers. However, the correlation was low between youth and service provider ratings of alliance. Longitudinal analyses indicated that rates of therapeutic alliance changed over time.     

Unpacking barriers to quality care for Deaf people in residential aged care facilities

Residential aged care providers often face difficulties in meeting the needs of residents with a lifelong disability. In this article, I explore these issues from the perspective of signing Deaf residents. While previous studies have documented a number of issues around staff training and communication for Deaf residents, there remains a dearth of literature considering the root causes of these problems. Drawing on interviews with a variety of service providers, this article suggests a number of ways current practices might be improved as well as discussing funding changes required to ensure Australian Deaf residents do not fall through the cracks.     

The influence of the economic crisis on quality of care for older people: system readiness for innovation in Europe

The aim of this study is to examine the influence of the recent economic crisis on the quality of long-term care for older people in Belgium and the Netherlands. A mixed-method approach was applied, primarily focused on conducting semi-structured qualitative interviews with health professionals working in a management role in organizations providing long-term care for older people. The results show that Dutch organizations seem to be prepared for the influences of the economic crisis on the quality of its care provision primarily in terms of a sound system readiness. At the same time, Belgian organizations seem to be prepared for the influences of the economic crisis on the quality of its care provision primarily in terms of a favorable sociopolitical context. Comparing two countries allows for reciprocal lesson-drawing. The conclusion drawn in this study is that a sustainable long-term care system requires above all stability and structure.     

From pipeline to practice: Utilizing tracking mechanisms for longitudinal evaluation of physician recruitment across the health workforce continuum

PurposeArea Health Education Centers work with community partners to prepare a diverse, primary care workforce particularly among rural and underserved communities. We set out to assess our impact on the physician workforce across a multitude of short-term, intermediate, and long-term benchmarksMethodWe used a comprehensive evaluation scaffolding to assess benchmarks of success across the workforce pipeline including short-term (i.e. pre-medical intent to pursue a health career or medical students’ intent to practice in primary care), intermediate (college matriculation and primary care residency match rates) and longterm measures (licensure and medical practice location of program participants).ResultsWe identified significant findings in each part of the AHEC program continuum. Among our alumni, we found a significant increase in the pre-medical learner’s intent to pursue a health care career. Among medical students, we found a significant increase in intent to practice in primary care, rural areas, and medically underserved communities and a high rate of primary care residency match (compared to peers). Approximately one-third of licensed physicians are now practicing medicine serve in an underserved communityConclusionsOur findings confirm the value of longitudinal evaluation on confirming that participation in an AHEC supported program strengthen the physician workforce development.     

Predictors of out-of-pocket medical expenditures in low-income households

From a sample of low-income households, out-of-pocket medical expenses are found to average about $25 per month. For each household, these expenses vary with annual income, type of insurance for medical care, priority of medical expenses, ethnicity, and number of ill family members. Expenses are reported for households with different socioeconomic characteristics and composition. Multiparticipation in insurance programs is shown. Fourteen percent of the survey participants say they have no insurance, public or private. Thirty-three percent participate in Medicaid.Flora L. Williams is an Associate Professor in Consumer Sciences and Retailing at Purdue University, West Lafayette, IN 47907. She received her Ph.D. from Purdue University and includes family economic well-being, and financial problems and expenditures among her research interests.Amy Hagler received her M.S. from Purdue University in Consumer Sciences and Retailing.Mary Pritchard is an Associate Professor in the Department of Human and Family Resources at Northern Illinois University, DeKalb, IL 60115-2854. Her Ph.D. was earned at Purdue and her areas of research focus on family economic well-being and economic socialization of adolescents.Marshall A. Martin is a Professor of Agricultural Economics at Purdue University. His research addresses agriculture and food policy, and economic assessment of emerging agricultural technology.William C. Bailey is an Assistant Professor of Marketing at the University of Indianapolis, 1400 E. Hanna Avenue, Indianapolis, IN, 46227-3697. He received his Ph.D. from Texas Tech University and focuses his research on economic psychology and health care cost.     

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.