Federal Insurance Program Research Articles

Beyond Localism: Harnessing State Adaptation Lawmaking to Facilitate Local Climate Resilience

Notwithstanding the need for adaptation lawmaking to address a critical gap between climate-change related risks and preparedness in the United States, no coherent body of law exists that is aimed at reducing vulnerability to climate change. As a result of this gap in the law, market failures, and various “super wicked” attributes of hazard mitigation planning, local communities remain unprepared for present and future climate-related risks. Many U.S. communities continue to employ land-use planning and zoning practices that, at best, fail to mitigate these hazards, and, at worst, increase local vulnerability. Even localities that have implemented otherwise robust adaptation plans tend to focus almost entirely on accommodation strategies, even when retreat strategies are warranted. The result is the continued use of land-use planning and zoning practices that allow for intensified land uses in risk-prone areas. Such maladaptive development carries with it current and future costs from locking in infrastructure and patterns of development that place people and property in harm’s way. When addressing this preparedness gap, many scholars focus on flaws in the federal flood insurance and disaster assistance programs. This Article builds on a small but growing literature on the potential for land use and other local lawmaking regimes to proactively facilitate climate resilience, and the barriers local governments face that cause them to continue to promote maladaptive development. Using New York’s recently enacted adaptation law as a case study, I ask whether state mandates and incentives, although facially limiting of local autonomy, are nevertheless needed to empower local governments to overcome otherwise intractable obstacles to decreasing the intensity of development in vulnerable areas. I conclude by identifying specific attributes of state adaptation lawmaking that may be needed to support and encourage local government efforts to promote resilience. Ultimately, I conclude that, by helping local governments overcome barriers to robust adaptive development, state lawmaking has the potential to empower local governments to proactively move people and infrastructure out of harm’s way.

Healthcare utilization and expenditures for United States Medicare beneficiaries with systemic vasculitis.

The Medicare federal insurance program is the most common United States insurer of patients with systemic vasculitis (SV). We compared healthcare utilization and expenditures for Medicare beneficiaries with versus without SV. This national, retrospective study used 2010 claims and enrollment data for a 100% cohort of Medicare Part A and B beneficiaries with ≥1 claim including a diagnosis for a form of SV (n = 176,498), and a randomly selected group of non-SV beneficiaries (n = 46,561). Outcomes included annual counts of events in 16 categories of medical services (e.g., inpatient stays, physician visits, tests, and imaging events), and total annual Medicare and patient medical expenditures. We used linear regression with bootstrapped standard errors to compare utilization and expenditures by SV status, before and after matching on age and sex. Prescription drug fills and expenditures for SV (n = 95,157) and non-SV (n = 24,992) beneficiaries with Part D drug benefits were also compared. After matching, Medicare spent $11,004 more per patient in 2010 for medical services, and $773 more on prescription drugs, for SV versus non-SV beneficiaries. SV beneficiaries spent $1547 more for medical services and $211 more for prescription drugs. Except for hospice, SV beneficiaries had greater utilization of all services, including two-to-three times more dialysis events, hospital readmissions, inpatient stays, skilled nursing facility stays, and medical tests. The average Medicare beneficiary with SV incurs about double the annual healthcare expenditures compared to their non-SV counterparts, attributable to increased utilization of almost all categories of care.

Crop Insurance in the EU: Lessons and Caution from the US

SummaryRecent changes in the Common Agricultural Policy suggest the possibility of an enlarged crop insurance programme in Europe (Art. 37–39 of EU Reg. 1305/2013). Several countries in the European Union already have national crop insurance schemes, but the performance of these programmes in terms of realised demand has been low, and at EU level the participation in crop insurance programmes is around 20 per cent. This situation can be contrasted with the federal crop insurance programme in the US which covers the majority of all agricultural land. We review the existing programmes in the EU and US to provide direction on two questions: is there any justification for subsidised crop insurance and how could such a scheme possibly be implemented in the EU? We argue that, while in the long run it may be desirable to establish an EU‐wide crop insurance programme, there are several serious impediments to implementation in terms of effectiveness and feasibility. A more immediate approach could be increased flexibility of national insurance systems. In particular, weather‐based index insurance and revenue insurance present possible solutions that may be worthy of consideration at the national level.

Students in Distress: Labor Market Shocks, Student Loan Default, and Federal Insurance Programs

The collapse in home prices during the Great Recession triggered a sharp drop in consumer demand by households, leading to massive employment losses. This paper examines the implications of these labor market shocks for the dramatic rise in student loan defaults, which originated during this time period. Linking administrative student loan data at the individual borrower level to de-identified tax records and exploiting Zip code level variation in home price changes, we show that the drop in home prices during the Great Recession accounts for approximately 24 to 32 percent of the increase in student loan defaults. Consistent with a labor market channel, we find a strong relationship between home prices, employment losses, and student loan defaults at the individual borrower level, which is concentrated among low income jobs. Comparing the default responses of home owners and renters, we find no evidence of a direct liquidity effect of home prices on student loan defaults. Lastly, we show that the Income Based Repayment (IBR) program introduced by the federal government in the wake of the Great Recession reduced both student loan defaults and their sensitivity to home price fluctuations, thus providing student loan borrowers with valuable insurance against adverse income shocks.

Navigating the Maze of New Regulations in the Final Rule

Navigating the Maze of New Regulations in the Final Rule

Say What? The Affordable Care Act, Medicare, and Hearing Aids

One of the most common consequences of aging is hearing loss, representing the third most prevalent chronic medical condition among seniors. Empirical evidence links hearing loss to a variety of other medical conditions, including depression, falls, and cognitive problems. Additionally, there is a demonstrated relationship between hearing loss and dementia. And yet, most insurance programs do not cover the cost of hearing aids. Even Medicare, the federal insurance program for those aged sixty-five and over, statutorily excludes coverage of hearing aids, which cost between $2,000 and $7,000 a pair.The Affordable Care Act (“ACA”), reflecting a radical departure from the goals embodied in the 1965 Medicare law, presents a lens for examining this issue anew. Numerous statutory provisions and the philosophy embodied in the ACA are useful catalysts for reform of the Medicare law. This Article elaborates on one specific provision of the ACA that could be utilized to authorize insurance coverage under the Medicare program. It also addresses other provisions in the ACA, including required preventive screenings and selected “Essential Health Benefits,” that, absent the Medicare exclusion, arguably would provide for such coverage. Acknowledging the tension between the ACA and Medicare law, this Article argues that the ACA is a useful tool for amending the Medicare law and eliminating this antiquated coverage exclusion. Finally, it suggests strategies for effectuating that result.

Federal Crop Insurance: The Need for Reform

Federal crop insurance is the largest federal property-casualty insurance program. Nominally, it is portrayed as a typical form of private property insurance. However, closer examination reveals that its structure departs significantly from conventional insurance principles and practices that are employed in private insurance markets. In reality, it is a greatly flawed and heavily subsidized wealth transfer program, costing taxpayers $3-$4 billion a year. Also, its flawed structure creates substantial adverse selection and moral hazard problems, encouraging farmers to make economically unsound investment and production choices with rippling effects for farm economies and the environment. Finally, the interaction of state regulation and the federal crop insurance program continues to raise issues that need to be resolved and could be diminished or eliminated if certain program reforms were implemented. In this paper, we critique the structural defects of the crop insurance program, identify the problems they create, and offer recommendations on how the program could be reformed to function more like a true insurance program based on sound economic principles and better coordination between state and federal governments.

Conning the IADC Newsletters

International Association of Defense Counsel Committee members prepare newsletters on a monthly basis that contain a wide range of practical and helpful material. This section of the Defense Counsel Journal is dedicated to highlighting interesting topics covered in recent newsletters so that other readers can benefit from committee specific articles. SIMILARITIES BETWEEN THE SAVINGS & LOAN CRISIS AND TODAY'S CURRENT FINANCIAL CRISIS: WHAT THE PAST CAN TELL US ABOUT THE FUTURE This article originally appeared in the September 2009 Fidelity and Surety Committee Newsletter. I. Introduction It goes without saying that the financial industry, along with numerous other sectors of the United States and global economies, are currently in peril. According to statistics posted on the Federal Deposit Insurance Corporation's (FDIC's) website, in 2008, twenty-five financial institutions failed in the United States; and as of July 7, 2009, 52 financial institutions already have failed in 2009. (1) By comparison, in 2007, only three banks failed, and in 2005 and 2006, no banks failed. (2) Along with this significant increase in bank failures, it is no surprise that financial institutions have been the main focus of litigation by both private parties and the government. Despite what some could refer to as sensationalism in the media regarding the unprecedented nature of the current crisis, this country weathered a similar collapse of its financial sector during the Savings & Loan (SL (2) the Federal Savings and Loan Insurance Corporation (FSLIC), which insured deposits in SL and (3) the Federal Deposit Insurance Corporation (FDIC), which regulated federally-chartered commercial banks and provided a federal deposit insurance program. …

Understanding the Increase in Disability Insurance Benefit Receipt in the United States.

The share of working-age Americans receiving disability benefits from the federal Disability Insurance (DI) program has increased significantly in recent decades, from 2.2 percent in the late 1970s to 3.6 percent in the years immediately preceding the 2007–2009 recession and 4.6 percent in 2013. With the federal Disability Insurance Trust Fund currently projected to be depleted in 2016, Congressional action of some sort is likely to occur within the next several years. It is therefore a good time to sort out the competing explanations for the increase in disability benefit receipt and to review some of the ideas that economists have put forth for reforming US disability programs.

A Guide Through the Medicare Morass: Medicare Fundamentals and Best Practices for Liability Insurers and Their Attorneys

SINCE its enactment, the mandatory Medicare reporting obligations of companies and insurers under U.S. federal law, i.e., 111 of the Medicare and Medicaid SCHIP Extension Act (MMSEA) of 2007, have been discussed extensively. (1) From an insurer's perspective, the laws are opaque and onerous. This article provides an overview of best practices under the Medicare laws to ensure that the obligations of both insurers and their attorneys are met. The article also addresses how different insurance arrangements change the Medicare reporting requirements and, in some instances, avoid them altogether. I. The Medicare Program Medicare is the federal government insurance program available to U.S. citizens and permanent residents who are 65 or older, have certain medical conditions or have received Social Security disability benefits for 24 months. (2) To understand 111 and how it has changed the nature of personal injury litigation and claims handling, some background information is helpful. The Medicare program was signed into law in 1965 but, in response to funding concerns, was amended in 1980 by the Medicare Secondary Payer Act (MSP Act). The MSP Act provided that Medicare may not pay for treatment or services provided to a Medicare beneficiary if another entity is legally or contractually obligated to provide such coverage. (3) The entity obligated for payment is known as the plan or payer. Medicare is, thus, a secondary payer. In the context of liability insurance, Medicare makes so-called on behalf of the beneficiary for medical treatment or services pending final settlement of a liability claim with the expectation of reimbursement from the liability insurer (also called the primary payer). However, the MSP Act lacked sufficient enforcement mechanisms to ascertain when reimbursement was possible from a primary payer and thus was unable to effectively ensure reimbursement. Accordingly, on December 29, 2007, the Medicare program was again amended in an effort to reduce government spending by enabling the agency responsible for administering Medicare (the Centers for Medicare and Medicaid Services or CMS) to better determine when another entity is responsible for the medical expenses of a Medicare beneficiary and ensure reimbursement for those Medicare-covered items and services that another entity is required to cover. This amendment has been dubbed Section 111 and requires any entity who makes a payment to a person eligible for Medicare arising out of a personal injury claim to report that payment to CMS. It is important to keep in mind that reporting is triggered by Medicare eligibility, not receipt of Medicare benefits. Reporting is done quarterly by submitting an electronic file on the Coordinator of Benefits Secure Website. (4) The Coordinator of Benefits Contractor (COBC) is a branch of CMS that is responsible for coordinating whether Medicare is entitled to reimbursement for any medical expenses and, if so, the total amount of reimbursement owed. Due to inefficiencies arising out of 111's implementation, on January 10, 2013, the Medicare laws were once again amended by the Strengthening Medicare and Repaying Taxpayers Act (SMART Act). Parties are now able to request the amount that Medicare has paid as conditional payments 120 days prior to the expected date of a settlement, and CMS is required to respond with the lien amount within 65 days (or 95 days if CMS determines additional time is needed). (5) The purpose of the provision is to enable parties to engage in mediation and settlement discussions with some idea as to the amount of the Medicare lien. Prior to this amendment, CMS was not obligated to respond within a specified time frame to a request for the amount of conditional payments, and settlements were delayed as a result. Additionally, CMS must establish each year a threshold amount that is exempt from 111 reporting equal to the amount that CMS incurs in attempting to collect conditional payments. …

Edward D. Berkowitz and Larry DeWitt. The Other Welfare: Supplemental Security Income and U.S. Social Policy.

Edward D. Berkowitz and Larry DeWitt have spent their careers honing a portrait of the centerpiece of the New Deal welfare state—the Social Security Act. Together, they have pulled its previously unknown architects into the limelight, illuminated lesser-known elements of the system, drawn connections to insurance expansions like disability and Medicare, and provided scholars and students with access to primary sources crucial to its historical development. From DeWitt's position as chief historian of the Social Security Administration and Berkowitz's perch as professor of history and public policy and public administration at George Washington University in Washington, D.C., they have modeled generous, cooperative scholarship. In their second collaboration, they bring their knowledge and experience to bear on a distant relation of Social Security in a much later period—the Supplemental Security Income Program (SSI). In the last quarter of the twentieth century, SSI emerged as a large, vital component of the welfare state, but its history, nevertheless, has been little-understood. SSI is a means-tested income-support program for the elderly and disabled who are not otherwise eligible for the larger federal disability insurance program, Social Security Disability Insurance. Created in 1972, SSI has come to serve over nine million Americans and continues to grow annually. Its architects in the Social Security Administration and Congress intended to include elderly and disabled adults as part of a more respectable, federally controlled welfare program—one more generous and more uniform than the previous Old Age Assistance program or the despised Aid to Families with Dependent Children, serving single mothers. In practice, however, the program fell short of those goals. Berkowitz and DeWitt demonstrate how SSI quickly evolved into a system as variable, vulnerable, and unpopular as many of the other means-tested “welfare” programs. Though policymakers desired a truly national program, compromises in the legislative and administrative processes left SSI at the mercy of state and congressional meddling. SSI paid radically different benefits from state to state as a result. The authors also track how shifting target populations generated hostility from lawmakers and the media. Though SSI initially aimed to provide support to the “respectable” elderly and disabled, increasing numbers of mentally disabled, mentally ill, and addicted adults and children soon populated the program. None of them proved to be popular or politically influential clientele. From the moment of the program's birth through the 1990s, journalists and disgruntled members of Congress attacked SSI's recipients. Today, despite the aims of its architects, SSI hovers just above Temporary Assistance for Needy Families and the food stamp program in the eyes of its critics.

Preventing Rodent Damage to Flood Control Facilities

Author(s): Lindsey, Pam | Abstract: In California, flood control facilities protect millions of people and critical infrastructure from flood events by containing water and debris behind engineered structures. Rodent burrow damage to flood control dams and levees results in failure to meet federal and state structural certification criteria. Non-certified structures pose substantial damage risks during flood events and are ineligible for federal flood insurance and reimbursement programs. Most dams and levees are compacted earth, faced with rock, and topped with gravel access roads. These facilities provide excellent habitat for ground squirrels; the rocks provide cover and the creeks, neighborhoods and nearby agricultural fields provide abundant food. Ground squirrels form the base of the food chain for raptors, coyotes, bobcats, and mountain lions, which routinely foraging along facilities. The Ventura County Watershed Protection District developed an Integrated Pest Management Program (IPMP) to prevent rodent damage to flood control facilities. We found that small amounts of anticoagulant (diphacinone) in bait stations along flood control facilities target ground squirrels with low risk to other fauna. The California Department of Fish and Wildlife, other conservation agencies, and members of the public have requested anticoagulant use be terminated to avoid secondary poisonings. Alternative controls do not provide the level of protection necessary to meet structural criteria. The current registered diphacinone label requires verification of pest infestations before application. However, infestation must be prevented at flood control facilities. Treating the few dispersing squirrels avoids treating an entire colony with anticoagulants, and therefore much less bait enters the food chain. Ventura County lobbied to change the label to allow some bait to be left in the bait stations to control dispersing squirrels. Discontinuing diphacinone is not yet an option, but we plan to conduct studies to further improve bait station design and bait application protocols, coordinate with neighboring landowners, and revise the IPMP to reduce bait use.

Abstract B54: Addressing cancer disparities in the border region: A novel model of twinning in pediatric oncology.

Abstract Background: Health institutions located along the borders of countries with profound economic disparities often face difficulties in providing care for children with complex diseases such as cancer. Until recently, many children with cancer from Baja California went untreated. We postulated that the St. Jude Children's Research Hospital (SJCRH) twinning model used to improve pediatric cancer care in low income countries could successfully be applied in this particular setting to reduce disparities in care. The impact of twinning programs has already been proven. Twinning is defined as a form of cooperation between centers in developed countries and low-income countries, whereby knowledge and organizational skills are shared and pediatric oncology units are established in a culturally sensitive manner and adapted to local health care systems. SJCRH has established several successful twinning programs worldwide. Objectives: In 2008, Rady Children's Hospital San Diego (RCHSD) partnered with SJCRH and Hospital General-Tijuana (HGT), the largest hospital in northwestern Mexico, to initiate a twinning project aiming to establish a fully functional pediatric oncology unit and to improve care for children with cancer in the border region. Methods: A modified SJCRH assessment tool was developed and revealed that, although the basic hospital infrastructure and services, were available (e.g.: anatomic pathology, laboratory and blood bank) the essential elements of a pediatric cancer unit, such as dedicated space, trained pediatric oncologists and nurses and uniform treatment were lacking. In addition, chemotherapy medications were available but not prepared according to proper procedure; medical records were incomplete; patients had no access to intensive therapy; and supportive care programs were lacking. A 5-year strategic plan was designed to provide salary supplementation for health care professionals, intensive education and training, and infrastructure improvement. A bicultural, Spanish-speaking pediatric oncologist from RCHSD was appointed to supervise the project and visited the partner site weekly to monitor progress closely. Results: After four years, accomplishments include: the opening of a new isolated inpatient unit with updated technology, the training of nurses and staff, and the establishment of a dedicated inter-disciplinary team led by two local pediatric oncologists. Over 160 patients have benefited from accurate diagnosis and treatment, access to supportive care, infection control, specialized nurses, dedicated pediatricians, and psychosocial and nutritional programs. In December 2008, the pediatric oncology service at HGT received the Mexican Accreditation ensuring full coverage by a Federal insurance program for the underprivileged and contributing to local sustainability. Conclusion: Border towns have a particularly high need for the development of programs to address health disparities. Initiatives in the border region constitute a unique model of twinning, since the proximity permits close follow-up and leads to establishment of reducing disparities programs in record time, benefiting hundreds of children. Ongoing initiatives include, continued education and training for the staff and the community, a shelter for patients and expansion of education and subsidies for families. Citation Format: Paula Aristizabal, Raul C. Ribeiro, William D. Roberts. Addressing cancer disparities in the border region: A novel model of twinning in pediatric oncology. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr B54.

Explaining the Lack of Non-Public Actors in the U.S. Public Social Insurance System

There are currently very few non-public actors playing a role in the federal and state social insurance programs in the United States. Yet, “projected long-run program costs for both Medicare and Social Security are not sustainable under currently scheduled financing, and will require legislative corrections if disruptive consequences for beneficiaries and taxpayers are to be avoided.” As financial pressure increases on these programs, as it surely will, Americans may become more willing to go the privatization route and engage more non-public actors in the provision of social insurance.In the meantime, the paradox of the American social insurance system is that while disclaiming any desire for socialist-type programs, most Americans today believe that only the government should be responsible for providing the social insurance safety net. On the one hand, this could be because U.S. citizens are seeking to hold on to what meager social safety net they have left. On the other hand, scarred from the recent global recession and underhanded actions by many private investment firms and banks, most Americans are not yet ready to place their faith in these private actors, even if more efficiency, cost-savings, and activation could be achieved by doing so.What this all means is that unlike its counterparts in Europe, the United States social insurance system does not appear to have an incipient movement in which non-public actors will start to play a larger role in any American social insurance program in the near future. At the same time, the stability of the current system means there is unlikely to be the same diminishment in solidarity that is sometimes seen with the introduction of non-public actors into these programs in other countries.

Medicare prescription drug plan coverage of pharmacotherapies for opioid and alcohol dependence in WA

Pharmacotherapeutic treatments for drug addiction offer new options, but only if they are affordable for patients. The objective of this study is to assess the current availability and cost of five common antiaddiction medications in the largest federal medication insurance program in the US, Medicare Part D. In early 2010, we collected coverage and cost data from 41 Medicare Part D prescription drug plans (PDPs) and 45 Medicare Advantage Plans (MAPs) in Washington State. The great majority of Medicare plans (82-100%) covered common pharmacotherapeutic treatments for drug addiction. These Medicare plans typically placed patent protected medications on their highest formulary tiers, leading to relatively high patient co-payments during the initial Part D coverage period. For example, median monthly co-payments for buprenorphine (Suboxone®) were about $46 for PDPs, and about $56 for MAPs. While Medicare prescription plans usually cover pharmacotherapeutic treatments for drug addiction, high co-payments can limit access. For example, beneficiaries without supplemental coverage who use Vivitrol® would exceed their initial coverage cap in 7-8 months, reaching the "doughnut hole" in their Part D coverage and becoming responsible for the full cost of the medication (over $900 per month). The 2010 Patient Protection and Affordable Care Act will gradually eliminate this coverage gap, and loss of patent protection for other antiaddiction medications (Suboxone® and Campral®) should also drive down patient costs, improving access and compliance.

SCHIP Expansion Bedeviled by Cost Concerns

Back to table of contents Previous article Next article Government NewsFull AccessSCHIP Expansion Bedeviled by Cost ConcernsRich DalyRich DalySearch for more papers by this authorPublished Online:21 Sep 2007https://doi.org/10.1176/pn.42.18.0004Opponents and advocates of a massive expansion of the State Children's Health Insurance Program (SCHIP) agree that some privately insured children will switch to a publicly backed health program if they are made eligible, but the two sides differ on whether that “crowd out” is reason enough to not expand coverage.The argument has been a key issue in the ongoing legislative battle to reauthorize and expand SCHIP. Each chamber of Congress has passed a bill to expand the federal and state insurance program, but President Bush has argued the expansion is too large and would crowd out too many children already privately insured (Psychiatric News, September 7).The House and Senate are negotiating compromises on the two bills (HR 3162 and S 1893) passed before the August recess, which would insure an additional 5 million or 4 million uninsured, respectively, beyond the 6 million children already covered under SCHIP.These proposed SCHIP enrollees do not include new enrollees crowded out of private insurance. The Congressional Budget Office (CBO) estimates that the program expansions in the House bill would cover 2.4 million minors with private insurance and other health coverage, and the Senate bill would add 2.1 million such children.President Bush had proposed a smaller expansion of the program and has promised to veto the House and Senate versions.The impact of crowding out such children, who are overwhelmingly healthy, is that their participation and their families' participation in private employers' health plans help hold down their overall costs because children's expenses are well below their premium payments, according to Janet Trautwein, vice president of government affairs for the National Association of Health Underwriters, who joined other officials in an Alliance for Health Reform discussion of the issue in August.She and other critics of the larger expansions said the government could more efficiently achieve broader insurance coverage through a subsidy of private insurer plans, beyond existing tax breaks.“Our research found it would be less expensive for the government to subsidize those plans,” she said.However, CBO research indicates that the Senate and House approaches are among the most efficient plans offered to cover a larger number of uninsured children with the smallest amount of crowd out, said CBO Director Peter Orszag.Supporters of the SCHIP expansion bills said they each include measures to encourage states to focus the programs on children without insurance coverage.“Crowd out is an inevitable byproduct of any effort to increase government coverage,” said Lisa Dubay, Ph.D., an associate professor of health policy management at Johns Hopkins Bloomberg School of Public Health.However, Dubay said, no evidence has emerged to indicate that crowd out has led any employers to reduce coverage.The issue of crowd out was again raised during Congress's August recess when the Centers for Medicare and Medicaid Services (CMS) ordered new restrictions on the income thresholds of SCHIP-funded programs, which would limit states to covering children whose family incomes are up to 250 percent of the federal poverty level, or $42,925 a year for a family of three (see chart).The order directs any state that seeks to expand eligibility for SCHIP-funded children's health plans to those earning more than that 250 percent of the federal poverty level to adopt “crowd-out strategies,” designed to prevent those who might otherwise pay for coverage from private insurers from enrolling in government plans. They include a mandatory one-year waiting period during which individuals must be uninsured before they receive coverage.Ann Clemency Kohler, New Jersey's deputy commissioner of human services, said such crowd-out mandates would have a major impact in New Jersey and other high-cost states, where children from families with incomes up to 350 percent of the federal poverty level are eligible for SCHIP.“We have an incredibly high cost of living,” she said.“ Families with those incomes are actually doing poorly, and the state wants to help them.”She and other expansion advocates said the data indicate that many of the children had insurance earlier in the year they enrolled in SCHIP but lost that insurance through their parents' job loss or discontinuation of insurance coverage by a parent's employer.Another mandate from the August CMS order requires states to certify that at least 95 percent of children already eligible for health care coverage under SCHIP are receiving that coverage before expanding above 250 percent of the federal poverty level. Kohler said that level of SCHIP enrollment has never been achieved by any state.The administrative attempts to reduce crowd out may never go into effect, according to some critics, because congressional leaders are likely to override them legislatively before they go into effect.Further information on insurance crowd out is posted at<www.allhealth.org/event_reg.asp?bi=112>.▪ ISSUES NewArchived

Counting the Ways: The Structure of Federal Spending

Public discussion of federal fiscal policy typically focuses on several familiar metrics of performance, including the total deficit, the level of public debt and percentage of federal spending committed to mandatory spending and net interest payments. While useful, these measures are based on accounting conventions developed years ago, and do not capture many of the ways in which the federal government now commits public resources, including obligated budget authority, guarantees associated with various government insurance programs, retirement benefits for federal workers and military personnel, and - most substantially - federal social insurance programs such as Social Security and Medicare. Collectively these programs and activities represent substantial and largely overlooked current commitments of future federal resources. After reviewing current measures of fiscal performance, the article presents several alternative ways to quantify federal financial performance over the first half of this decade utilizing more comprehensive measures of mounting federal financial obligations. So, for example, while the commonly reported total deficit of the federal government in FY2005 was $318 billion, a more comprehensive measure of fiscal results over the course of the same year would have shown a deterioration in the country's net financial position in excess of $3.3 trillion - that is, an order of magnitude larger. To promote more informed debate and encourage more responsible public leadership, the more comprehensive measures of fiscal performance described in this article should be adopted as the primary metrics for reporting the financial performance of the federal government. (US, Canada).

The Making of a Colonial Welfare State

Early-twentieth-century Puerto Rican women’s and labor groups advocated for public support for economically needy groups to little avail, given the fiscal limitations of the early colonial state. The exclusion of Puerto Rico from the comprehensive social welfare embodied in the Social Security Act of 1935 was rooted in U.S. Congressional resistance to statehood for selected territories. The platform of the Partido Popular Democrático (Popular Democratic party—PPD), which merged elements of Puerto Rican nationalism with a foreign-investment-and-export-dependent development strategy, further distanced Puerto Ricans from participation in federal welfare programs. The PPD’s economic program yielded rapid initial growth followed by stagnation. Resulting unemployment and declining consumer demand led to a gradual reversal of U.S. social welfare policy toward Puerto Rico. Beginning in the 1950s, federal social insurance and public assistance programs were extended to Puerto Rico, albeit with funding restrictions not imposed on the states.

Federal Credit and Insurance Programs: Housing

This paper reviews the evolution of the major credit and insurance programs undertaken by the U.S. government in support of urban housing. As the review makes clear, the Federal Housing Administration (FHA), Veterans Administration, Federal National Mortgage Association, and Federal Home Loan Mortgage Corporation have played major roles in the development of liberal and efficient primary and secondary mortgage markets in the United States. The development of capacity in mortgage lending and securitization in the private sector does suggest, however, that federally subsidizing mortgage market activities can be restrained with little effect on homeownership- the principal goal of this federal activity. In particular, the orderly reduction in the mortgage investment activities of the government-sponsored enterprises (GSEs) and the imposition of guarantee fees on mortgage-backed securities insured by the GSEs are first steps in restraining federal activity. More generally, a concentration of FHA and GSE activity on first-time homebuyers would reduce federal risk exposure while preserving the economic rationale for government activity.

Inequality of Access to Surgical Specialty Health Care: Why Children With Government-Funded Insurance Have Less Access Than Those With Private Insurance in Southern California

More than 25 million children in the United States are dependent on federal and state medical insurance programs for their health care needs. In California, 3.25 million children depend on Medi-Cal for their health insurance. In Southern California alone, the figure is as high as 1.81 million. However, 9.30 million children nationally and 1.55 million in California have no health insurance. Various public policies that would increase enrollment in these programs are being discussed to address this problem. However, before their implementation, it is important to understand what impact such policies would have on the actual delivery of health care to this patient population. In California, 2 predominant health care delivery models exist for Medi-Cal: a fee-for-service (so-called regular or straight Medi-Cal) and a managed care plan. One third of the children in Medi-Cal in the state are enrolled in the fee-for-service plan with the remainder in the managed care plan, whereas in Southern California, this figure is slightly lower at 28% in the fee-for-service plan. The objective of this study was to determine the number of otolaryngologists in Southern California who would offer a new patient appointment for an evaluation for tonsillectomy for a child with commercial insurance versus government-funded (Medi-Cal) insurance through direct contact with the physician and to determine whether the surgeon would offer to perform the procedure or refer the patient to another institution and to identify the specific reason(s) for any disparity in access to health care. A written questionnaire was sent via regular mail to 303 otolaryngologists in the Southern California area in 2003. A total of 100 fully completed questionnaires were received. Ninety-seven surgeons would offer an office appointment to a child with commercial insurance as compared with only 27 for a child with Medi-Cal. Of those 27 surgeons, 8 would then refer the child to another physician to perform the surgery, and only 19 would actually offer to perform surgery, if indicated. Reasons provided for not offering an office appointment or surgery for the child with Medi-Cal include excessive paperwork and/or administrative burdens (96%), low monetary reimbursement for the surgery (92%), and low monetary reimbursement for the office visit (87%). There is a tremendous inequality of access to surgical specialty health care for children with government-funded insurance when compared with those with commercial insurance in Southern California. Physicians indicate that this disparity is related to excessive administrative burdens and low monetary reimbursement. The implications of our findings on public health care policies are discussed.