Journal of Health Politics Policy and Law最新文献

Context: In 2015, the Centers for Medicare and Medicaid Services (CMS) urged state Medicaid programs to use 1115 waiver demonstrations to expand substance use treatment benefits. We analyzed four critical points in states' decision-making processes before expanding benefits.

Methods: We conducted qualitative cross-case comparison of three states that were early adopters of the 1115 waiver request. We conducted 44 interviews with key informants from CMS, Medicaid, and other state agencies, providers, and managed care organizations.

Findings: Policy makers expanded substance use treatment in response to "fragmented" care systems and unsustainable funding streams. Medicaid staff had mixed preferences for implementing new benefits via 1115 waivers or state plan amendments. The 1115 waiver process enabled states to provide coverage for residential benefits, but state plan amendments made other services permanent parts of the benefit. Medicaid agencies relied on interorganizational networks to identify evidence-based practices. Medicaid staff secured legislative support for reform by focusing on program integrity concerns and downstream effects of substance use rather than Medicaid beneficiaries' needs.

Conclusions: Decision-making processes were influenced by Medicaid agency characteristics and interorganizational partnerships, not federal executive branch influence. Lessons from early-adopter states provide a road map for other state Medicaid agencies considering similar reform.

Researchers have begun to examine whether centralized or decentralized (or federal) political systems have better responded to the COVID-19 pandemic. In this article, we probe beneath the surface of China's political system to examine the balance between centralized and decentralized authority in China's handling of the pandemic. We focus not on the much-studied later response phase but on the detection and early response phases. We show that after the SARS epidemic of 2003, China sought to improve its systems by both centralizing early infectious disease reporting and decentralizing authority to respond to local health emergencies. But these adjustments in the central-local balance of authority after SARS did not change "normal times" authority relations and incentive structures in the political system-indeed they strengthened local authority. As a result, local leaders had both the enhanced authority and the incentives to prioritize tasks that determine their political advancement at the cost of containing the spread of COVID-19. China's efforts to balance central and local authority show just how difficult it is to get that balance right, especially in the early phases of a pandemic.

Context: American Indian elders have a lower life expectancy than other aging populations in the United States because of inequities in health and in access to health care. To reduce such disparities, the 2010 Affordable Care Act included provisions to increase insurance enrollment among American Indians. Although the Indian Health Service remains underfunded, increases in insured rates have had significant impacts among American Indians and their health care providers.

Methods: From June 2016 to March 2017, we conducted qualitative interviews with 96 American Indian elders (age 55+) and 47 professionals (including health care providers, outreach workers, public-sector administrators, and tribal leaders) in two southwestern states. Interviews focused on elders' experiences with health care and health insurance. We analyzed transcripts iteratively using open and focused coding techniques.

Findings: Although tribal health programs have benefitted from insurance payments, the complexities of selecting, qualifying for, and maintaining health insurance are often profoundly alienating and destabilizing for American Indian elders and communities.

Conclusions: Findings underscore the inadequacy of health-system reforms based on the expansion of private and individual insurance plans in ameliorating health disparities among American Indian elders. Policy makers must not neglect their responsibility to directly fund health care for American Indians.

Context: States have experimented with the income eligibility threshold between Medicaid coverage and access to subsidized Marketplace plans in an effort to increase coverage for low-income adults while meeting other state priorities, particularly a balanced budget. In 2014, Wisconsin opted against adopting an ACA Medicaid expansion, instead setting the Medicaid eligibility threshold at 100% of the poverty level-a state-funded partial expansion. Childless adults gained new eligibility, while parents and caregivers with incomes between 101-200% of poverty lost existing eligibility.

Methods: We used Wisconsin's all-payer claims database to assess health insurance gains, losses, and transitions among low-income adults affected by this partial expansion.

Findings: We found that less than one third of adults who lost Medicaid eligibility definitely took up commercial coverage, and many returned to Medicaid. Among those newly eligible for Medicaid, there was little evidence of crowd-out. Both groups experienced limited continuity of coverage. Overall, new Medicaid enrollment of childless adults was offset by coverage losses among parents and caregivers, rendering Wisconsin's overall coverage gains similar to nonexpansion states.

Conclusions: Wisconsin's experience demonstrates the difficulty in relying on the Marketplace to cover the near poor and suggests that full Medicaid expansion more effectively increases coverage.

Context: The accuracy of provider directories and whether consumers can schedule timely appointments are crucial determinants of health access and outcomes.

Methods: We evaluated accuracy and timely access data obtained from the California Department of Managed Health Care, consisting of responses to large, random, representative surveys of primary care providers, cardiologists, endocrinologists, and gastroenterologists for 2018 and 2019 for all managed care plans in California.

Findings: Surveys were able to verify provider directory entries for the four specialties for 59% to 76% of listings or 78% to 88% of providers reached. We found that consumers were able to schedule urgent care appointments for 28% to 54% of listings or 44% to 72% of accurately listed providers. For general care appointments, the percentages ranged from 35% to 64% of listed providers or 51% to 87% of accurately listed providers. Differences across markets related to accuracy were generally small. Medi-Cal plans outperformed other markets with regard to timely access. Primary care consistently outperformed all other specialties. Timely access rates were higher for general appointments than for urgent care appointments.

Conclusions: Our finding raise questions about the regulatory regime as well as consumer access and health outcomes.

Context: Over the last two decades a growing body of research has shown that authoritarian regimes are trying to increase their legitimacy by providing public goods. But there has so far been very little research on whether or not these regimes are successful.

Methods: This article analyzes data from a 2012-2013 nationally representative survey in China to examine whether health care provision bolsters the Communist regime's legitimacy. Using multivariate ordinal logistic regression, we test whether having public health insurance and being satisfied with the health care system are associated with separate measures of the People's Republic of China's regime legitimacy: support for "our form of government" (which we call "system support") and political trust.

Findings: Having public health insurance is positively associated with trust in the Chinese central government. Health care system satisfaction is positively associated with system support and trust in local government.

Conclusions: Health care provision may bolster the legitimacy of authoritarian regimes, with the clearest evidence showing that concrete benefits may translate into trust in the central government. Further research is needed to understand the relationship between trends in health care provision and legitimacy over time and in other types of authoritarian regime.