Citation URL: http://www.urban.org/JoshuaMWiener

The demand for long-term care services will surge in coming decades when the baby boomers reach their 80s. Declining family sizes, increasing childlessness, and rising divorce rates will limit the number of family caregivers. Rising female employment rates may further reduce the availability of family care, increasing the future need for paid home care. This study projects to 2040 the number of people ages 65 and older with disabilities and their use of long-term care services. The simulations show that even under the most optimistic scenario long-term care burdens on families and institutions will increase substantially.

Frail older adults are one of the most vulnerable groups in the nation. Disproportionately female, widowed, and in their 80s and 90s, most older people with disabilities living outside of nursing homes have little education and limited financial resources. Given the scarcity of public financing for home-based care, about three-quarters of those receiving assistance rely exclusively on unpaid caregivers. Providing help is often a burden on spouses, children, and friends, leaving some older Americans without the care they need. As the population ages, the demands on government and families will only intensify and put more older people at risk.

This chapter explains how American federalism apportions responsibility for domestic policy between federal and state governments, and sometimes localities, often in overlapping ways. Arguments for relying on states versus the federal government can be grounded in political philosophy. Market principles also contribute to federalism debates. Finally, pragmatic considerations seem most important for most issues, most of the time. Citizens and policymakers decide what government performs best on a particular issue in their era. Thus, how states have exercised their enhanced authority in our New Federalism era matters a great deal. (25-57 in Federalism and Health Policy, edited by John Holahan, Alan Weil, and Joshua M. Weiner (Washington, DC: The Urban Institute Press, July 2003).)

The balance between state and federal health care financing for low-income people has been a matter of considerable debate for the last 40 years. Some argue for a greater federal role, others for more devolution of responsibility to the states. Medicaid, the backbone of the system, has been plagued by an array of problems that have made it unpopular and difficult to use to extend health care coverage. In recent years, waivers have given the states the flexibility to change many features of their Medicaid programs; moreover, the states have considerable flexibility to in establishing State Children’s Health Insurance Programs. This book examines the record on the changing health safety net. How well have states done in providing acute and long-term care services to low-income populations? How have they responded to financial incentives and federal regulatory requirements? How innovative have they been? Contributing authors include Donald J. Boyd, Randall R. Bovbjerg, Teresa A. Coughlin, Ian Hill, Michael Housman, Robert E. Hurley, Marilyn Moon, Mary Beth Pohl, Jane Tilly, and Stephen Zuckerman.

The current balance of responsibility between states and the federal government for low-income people’s health coverage has achieved a great deal. It covers many of the neediest people, supports the safety net, responds to emerging needs, and supports some experimentation. However, it leaves more than forty million people uninsured, allows excessive variation across states, places unsustainable pressure on state budgets, creates tensions between the levels of government, and yields too few benefits from experimentation. This mixed record argues for a significant simplification of and increase in eligibility for public programs, with the federal government either providing extra funds to states to meet these needs or assuming full responsibility for insuring the poor. (Health Affairs Web Exclusive, July 16, 2003.)

This paper describes the Medicaid work incentives and how they are being implemented at the state level. It explores the major issues involving Medicaid and work incentives, including the state fiscal crises, horizontal equity across states and groups, coverage of needed services, defining disability, and the interaction between Medicaid and Social Security Disability Insurance and Medicare. In addition, the article also analyzes more technical design issues related to the Ticket to Work and Work Incentives Improvement Act work incentives, including definition of employment, age restrictions, and use of premiums.

The Centers for Medicare and Medicaid Services devised a pilot program in six states that has created a way to measure the quality of care in nursing homes. This installment of the Urban Institute series on "Public Interest" looks at how quality can be accurately measured and how standards are established and enforced.

[© Health Affairs] This cross-state analysis of 13 states found that states generally did not reduce or freeze payments to health care providers, limit efforts to promote enrollment in public health insurance programs, or cut benefits in response to the economic downturn. The states generally did not reduce eligibility in their Medicaid and SCHIP programs. Even if states continue to face budget pressures, eligibility cuts are unlikely because of the loss in federal matching funds that would result, minimum federal standards for eligibility, and the political strength of providers and beneficiaries. The researchers caution that the funding pressures on SCHIP and Medicaid -- rising healthcare costs and lower savings from managed care -- are long-term problems that are likely to continue even after the economy rebounds.

Based on site visit interviews with state officials, consumers, providers, and reviews of public documents and web sites, this report summarizes what happened to health care policy over the last few years in each of the following states: Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin. Among some of the general patterns found: Medicaid rolls dropped between 1995 and 1998 because of the improved economy and welfare reform, but have increased in more recent years. Welfare reform also allowed states to expand Medicaid eligibility to families with much higher incomes than previously. States responded to the enactment of SCHIP in 1997 by expanding coverage for children in families with relatively high incomes.

The past five years have given states new opportunities in health policy for low-income people, with many changes increasing states' flexibility. However, new pressures on state policy also have arisen from a variety of factors, most recently from the economic downturn that has reduced revenues and increased demand for spending. This paper analyzes recent changes in health policy in the thirteen states that are the core of the Urban Institute's Assessing the New Federalism project, focusing on state fiscal conditions, health care coverage, acute care, and long-term care. The paper concludes that the economic slowdown places severe pressure on state health policy but that these pressures will not end with the recession. Many problems are long term in nature – rising drug expenditures, the erosion of managed care's impact, quality of nursing home care and workforce shortage issues. These will all affect Medicaid spending and make it difficult for states to continue expanding coverage. (Health Affairs Web Exclusive 2002 May: 187-218)

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