Government Health Insurance Programs Research Articles

Health Insurance and Income Inequality.

Health insurance and other in-kind forms of compensation and government benefits are typically not included in measures of income and analyses of inequality. This omission is important. Given the large and growing cost of health care in the United States and the presence of large government health insurance programs such as Medicaid and Medicare, it is crucial to understand how health insurance and related public policies contribute to measured economic well-being and inequality. Our paper assesses the effect on inequality of the primary government programs that affect health insurance.

The Effects of Healthcare Provisions on the 4x Poverty Population in the United States

The patent protection and affordable care act provides tax credits and cost-sharing subsidies to households at or below 400 percent of the federal poverty threshold. To be eligible to receive these subsidies, one must not be insured under other government health insurance programs such as Medicare or Medicaid, and must have a federal poverty status between 133-400%, also known as the 4X poverty population. This tech report discusses the demographics and profile of the 4X poverty population, the dynamics of this population, and means of developing education and outreach methods to effectively inform this population of their eligibility for benefits. The population demographics are broken down at the state and city level as well as urban and rural areas. In terms of population dynamics, there were four different possible ways of moving in and out of the 4X poverty group from both the top edge (400%) and the bottom edge (133%). Through virtual experiments on taxpayer compliance, interventions such as mail and newspaper ads were tested to determine which best help educate the public about these benefits.

“You Lie!” Identity, Paper, and the Materiality of Information

This article uses the problems associated with citizenship verification in U.S. government health insurance programs to argue that paper needs to be analyzed as a media technology. To examine paper as a media technology is to ask, “How does paper work?” and “What are the rules and habits that enable paper to be used in paperwork?” To consider paper as a media technology, this article makes 2 arguments. First, it argues that there is a set of skills and knowledge associated with paper documents that need to be recognized as a distinct form of literacy. Second, this article argues that the relation between paper and identity is an argument about the materiality of information. In focusing on how paper facilitates the materialization of information, this case study illustrates how distinct practices of use create specific relationships between technology and information that give information a distinct functional presence.

Coalition portfolios and interest group influence over the policy process

An interest group coalition exists whenever two or more interest groups collaborate in advocating their public policy agendas. Working together in coalition is one of the most common tactics that interest groups use to advance their interests in the policy process. The extant literature on coalitions emphasizes interest group decisions to participate or not in one coalition, or their strategy toward coalitions in general, but gives insufficient attention to interest group participation in multiple coalitions. To rectify this deficit, this article examines the implications of groups’ participation in multiple coalitions for their ability to influence the policy process. In order to account for interest group involvement in multiple coalitions, we introduce the concept of the coalition portfolio, which is the set of all coalitions within a given area of public policy in which an interest group participates at a particular point in time. The portfolio concept recognizes that interest groups may have a wide variety of coalition strategies depending on the mix of coalitions that they join. Variations in the structure of these portfolios matter both to interest groups and to policymakers. Moreover, coalition portfolios evolve over time as coalitions form and dissolve, and as political conditions adjust over the course of the policy process. We develop and test hypotheses that the change in the composition of coalition portfolios increases the influence of interest groups over public policy when: (i) the number of coalitions in a group’s portfolio gets larger; (ii) the average size of the coalitions in a group’s portfolio gets larger or smaller; and (iii) a group’s portfolio improves its position within the overall network of coalitions. Network position is measured based on the betweenness of interest groups in coalition networks, which gives higher scores to groups that lie on the shortest paths between other groups. We test these hypotheses while accounting for other explanations for interest group influence, including: (i) the group’s position in communication networks; (ii) the group’s number of registered lobbyists working on Medicare; (iii) whether or not the group has a Political Action Committee; (iv) the extent to which a group’s lobbying contacts lean toward one political party; (v) whether or not the group endorsed the legislation in question; (vi) the organization’s age in years; and (vii) whether the group is a citizens advocacy organization, a business advocacy organization or some other organizational type. We evaluate these hypotheses using a study of 115 interest groups involved in the enactment and implementation of the Medicare Modernization Act of 2003. This legislation established an outpatient prescription drug benefit in Medicare – a government health insurance program for the elderly and disabled in the United States – and made other significant changes to the program. We conducted personal interviews with representatives of 102 of these groups. We analyzed data resulting from these interviews using negative binomial and ordinary least squares regression models. The results support Hypothesis (iii); groups gain influence over the policy process when their coalition portfolios increase the extent to which they are situated between other groups in the coalition network. However, interest groups are limited in the extent to which they can create portfolios that have desirable levels of betweenness because network position is also a function of membership decisions made by all other groups in the network. These results provide insight into how the composition of coalition portfolios affects the ability of interest groups to exert influence over the policy process. This analysis is most directly applicable to policy debates over complex pieces of legislation.

Federated States of Micronesia

Federated States of Micronesia John R. Haglelgam (bio) The beginning of this review period was particularly busy. The new national administration led by President Emanuel Mori had just been inaugurated and the political watchers were focusing on nominations for department heads. The first batch of nominees the president submitted included his uncle for secretary of resources and development, and his brother-in-law for FSM ambassador to the United States. The respective congressional committees favorably recommended the nominations for approval. However, the whole congress rejected both. Neither the reports of the jurisdictional committees nor the floor debates addressed the issue of nepotism, which was foremost in everyone's mind. Regardless, the political pundits knew that the two nominations were rejected because the nominees are close relatives of the president, who is from Chuuk State. In this particular case, the FSM public can heave a sigh of relief that the built-in checks and balances at the national level worked. The president nominated Makato Robert from Chuuk as his attorney general. At the time of his nomination, Robert was still facing charges of unethical practices in the FSM Supreme Court. In its report, the Judiciary and Governmental Operation Committee criticized the court for not acting promptly on the nominee's application for reinstatement to the FSM bar, but ignored the fact that the nominee still cannot appear before the FSM Supreme Court. Regardless of the deficiency in Robert's credentials, the FSM Congress took the bizarre action of approving his nomination. It is not clear how the new attorney general will represent the nation before the FSM Supreme Court, and how much damage this action has done to the reputation, image, and legitimacy of the national government. At the time of this writing, the Mori administration has filled almost all the major overseas posts with new ambassadors. Yosiwo George, the former governor and chief justice of Kosrae and most recently the manager of MiCare, the national government health insurance program, is the new FSM ambassador to the United States. John Fritz, a Japanese-educated Chuukese and longtime staff member of the embassy in Tokyo, has taken over from Kasio Mida as the ambassador to Japan. The former counsel general in Guam, Samson Pretrick, has become the new ambassador to Fiji. Masao Nakayama remains the head of the FSM Permanent Mission at the United Nations. Beijing is the only unfilled overseas post, but Carl Apis, a Pohnpeian, has been appointed as deputy chief of mission there. The consul general positions in Guam and [End Page 114] Honolulu are filled respectively by Gersen Jackson of Kosrae and Akilino Susaia of Pohnpei. Jackson is a former lieutenant governor of Kosrae, and Susaia served as the secretary of the Department of Economic Affairs under former President Joseph Ursemal. It is interesting to note that Masao Nakayama is the only remaining member of the old FSM diplomatic corp. Yosiwo George served a couple of years as head of the FSM mission at the United Nations in New York. Pretrick and Fritz are new in their posts but they are experienced diplomats. The two consul generals are new to diplomacy, but they are experienced administrators. The FSM president's cabinet consists almost entirely of new members. Finley Perman, a former official of the Pohnpei state government, now heads the Department of Finance and Administration; Lorin Robert, the former deputy secretary of foreign affairs, became the head of that department. Vita Skilling, a physician at the Kosrae state hospital, became the secretary of the new Department of Health and Social Affairs. The head of the newly renamed Department of Resources and Development is Peter Christian, the former Speaker of the national congress. Casiano Shoniber, the former Pohnpei state director of education, took over the new Department of Education. Francis Itimai, the former director of planning and budget in Yap, became secretary of transportation, communication, and infrastructure; the former head of that department, Andrew Yatilmal, now heads the Office of Environment and Emergency Management. Dr Rufino Mauricio remains the director of the newly expanded Office of National Archives, Culture, and Historic Preservation. Fabian Nimea, former manager of the Pohnpei Branch of the Bank of the FSM, becomes the director...

The Economic Impacts of Medicaid in North Carolina

The purpose of this study is to provide estimates of the economic impacts of Medicaid program expenditures in North Carolina in state fiscal year (SFY) 2003. The study uses input-output analysis to estimate the economic impacts of Medicaid expenditures. The study uses North Carolina Medicaid program expenditure data for SFY 2003 as submitted by the North Carolina Division of Medical Assistance to the federal Centers for Medicare and Medicaid Services (CMS). Industry structure data from 2002 that are part of the IMPLAN input-output modeling software database are also used in the analysis. In SFY 2003 $6.307 billion in Medicaid program expenditures occurred within the state of North Carolina-$3.941 billion federal dollars, $2.014 billion state dollars, and $351 million in local government funds. Each dollar of state and local government expenditures brought $1.67 in federal Medicaid cost-share to the state. The economic impacts within North Carolina of the 2003 Medicaid expenditures included the following: 182,000 jobs supported (including both full-time and some part-time jobs); $6.1 billion in labor income (wages, salaries, sole proprietorship/partnership profits); and $1.9 billion in capital income (rents, interest payments, corporate dividend payments). If the Medicaid program were shut down and the funds returned to taxpayers who saved/spent the funds according to typical consumer expenditure patterns, employment in North Carolina would fall by an estimated 67,400 jobs, and labor income would fall by $2.83 billion, due to the labor-intensive nature of Medicaid expenditures. Medicaid expenditure and economic impact results do not capture the economic value of the improved health and well-being of Medicaid recipients. Furthermore, the results do not capture the savings to society from increased preventive care and reduced uncompensated care resulting from Medicaid. State and local government expenditures do not fully capture the economic consequences of Medicaid in North Carolina. This study finds that Medicaid makes a large contribution to state and local economic activity by creating jobs, income, and profit in North Carolina. Any changes to the Medicaid program should be made with caution. The rising costs of health care and the appropriate role of government health insurance programs are the object of current policy debates. Informed discussion of these issues requires good information on the economic and health consequences of alternative policy choices. This is the first systematic study of the broader economic impacts of Medicaid expenditures in North Carolina.

Cost-effectiveness and evidence evaluation as criteria for coverage policy.

Private health plans and government health insurance programs in the United States base their coverage decisions on evidence criteria, rather than explicit cost-effectiveness criteria. As health spending continues to grow rapidly, however, approaches to coverage policy that ignore costs fail to meet the needs of consumers, employers, health plans, and federal and state governments. I describe the role of evidence-based criteria in formal coverage decision making and contrast the ways that these criteria differ from cost-effectiveness criteria. Finally, I discuss options for incorporating considerations of cost-effectiveness into coverage policy and other aspects of benefit design.

Hitting a moving target: income-related health insurance subsidies for the uninsured.

New government health insurance programs are likely to emphasize voluntary purchases in a market setting, with subsidies targeted at low-income populations and stress on managed care. Such programs are best structured with a guaranteed enrollment period that is as long as six months to a year. However, given that incomes change over time, errors will be made in awarding income-related subsidies for that long. These errors are assessed in simulations undertaken with longitudinal data from the Survey of Income and Program Participation. Two allocations of the subsidies, based on current income at the beginning of the enrollment period and on actual income assessed at the end, are compared for a variety of program designs. Prospective determination of subsidies is somewhat biased toward overpayment. Net overpayments amount to 5-10 percent of subsidy costs. However, prospective payment encourages participation in the subsidy program. The simulated participation rate for true eligibles is as high as 73 percent with prospective subsidies, compared to 69 percent with retrospective reconciliation. Net overpayments are slightly reduced by testing income less frequently and over longer periods.

Definition of race and ethnicity in older people in Medicare and Medicaid.

Race and ethnicity are important predictors of health care access and outcomes, but quality of their documentation in the healthcare system is often problematic. To study the agreement between Medicare and Medicaid descriptions of race and ethnicity in older beneficiaries. Quasiexperimental design in a natural practice setting. New Jersey. 153,241 dually enrolled participants in Medicare and Medicaid. Agreement rates between administrative databases on recipients' race and ethnicity. Agreement between Medicare and Medicaid on the recipients' race and ethnicity was modest (kappa = .58; 95% CI, .57-.58) for men and women alike and across different age groups. Depending on whether Medicare or Medicaid was used as the reference standard, the relative agreement rates for race and ethnic group assignments varied. For example, using Medicare as the reference, the relative agreement rate was 84% for whites, 74% for blacks, 61% for others, 23% for Hispanics, and only 5% for Asians. Using Medicaid as the reference, a different pattern emerged. However, such gradients of agreement rates across racial groups were observed in both programs. Medicare and Medicaid reported different percentages of all race and ethnicity groups, with Medicaid reporting greater proportions of White and Black beneficiaries, and Medicare reporting greater proportions of Hispanic, Asian, and Other groups. Depiction of race and ethnicity data in large government health insurance programs is approximate at best and often contradictory from one program to another. This can impede efforts to study the relationship between these important characteristics and health care utilization and outcomes.

Problems of health insurance coverage and health care in the United States: public and private solution strategies

A nearly universal consensus has developed in the United States that the current health care financing system is a failure. The system has been unable to control the continuing rapid rise in health care costs (by far, the highest in the world), and it has been unable to stem the growing population that has no health insurance coverage (at least 36 million people). There is nearly universal political agreement that government must provide health insurance to a far greater share of the population than ever before. The political debate now focuses on whether this expanded government role should supplement the private insurance system with an enlarged public program covering those left out of private insurance coverage, or replace private insurance with a universal government health insurance program covering the entire population.

The elderly's access to health care services: The crude and subtle impacts of Medicare changes

Medicare, the federal government's health insurance program for the aged and disabled, has been subjected to a number of legislative and regulatory changes since 1981 aimed at reducing the costs of the program. About a third of the cutbacks have been in activities that directly increase patient cost sharing. Other changes, while aimed at improving efficiency, may also shift costs onto program beneficiaries. This paper estimates the differential impacts of such program changes by age and income of elderly Medicare enrollees and discusses the likely resulting impact on their access to care. Surprisingly, such equity concerns have been largely overlooked in the policy debate concerning cost containment under Medicare.

A Model of the Change, Attributable to Government Health Insurance Plans, in Location Patterns of Physicians—With Supporting Evidence from Ontario, Canada

The introduction of government health insurance programs may induce physicians to change location trends that prevailed under previous market conditions. The subsequent change in geographic accessibility of people to medical services may be measured by the change in the stock of physicians per capita across space. An example of the Ontario Health Insurance Plan suggests that following its introduction, the change in the stock of physicians per capita is most sensitive to the initial stock of physicians and whether the physician is a specialist or not.

The Triumph of Accommodation: The Rise of Private Health Plans in America, 1929–1959

[The following is a chapter from Book Two of The Social Transformation of American Medicine and should be seen as a piece of a larger puzzle. Throughout the entire work I am concerned with the origins of the social and economic structure of medical institutions. One of the problems is the historical selection of organizational forms: why hospitals, clinics, public health agencies, medical schools, or, in this case, private health insurance and prepayment plans assumed distinctive organizational forms in the United States. These issues come up in the context of a more general argument about the development of the medical profession and its relation to the broader society. Book One deals with the initial loss and later recovery of professional authority, status, and control of the medical market between the late colonial period and the early twentieth century. The final chapters of Book One analyze the rise of organizations impinging upon private physicians (hospitals; public health institutions; corporations, fraternal societies, and private clinics) and try to account for the professions success in escaping both corporate and governmental control. Book Two then turns to the struggles over the politics and business of medicine in the twentieth century, from the debate about compulsory health insurance through the growth of corporate health care today. The first chapter, “The Mirage of Reform,” tries to explain the failure to pass a government health insurance program first during the Progressive era, again during the New Deal, and once again under President Truman. In the process of discussing these developments between 1915 and 1950, I try to delineate the changing political and economic forces that shaped the debate. Then, in the chapter below, I turn to the system that appeared in place of a public program and try to account for its organization.]

Health Expenditures in Canada and the Impact of Demographic Changes on Future Government Health Insurance Program Expenditures

Health Expenditures in Canada and the Impact of Demographic Changes on Future Government Health Insurance Program Expenditures

The medical profession and health insurance: An Ontario case study

Government health insurance programs in Canada represent innovations in public policy which are economic and social in nature. Initiated as cost-sharing agreements between the federal and provincial governments their purpose is to transfer responsibility for the direct costs of health care from the individual to the public purse. Within the provinces an equalization of costs as between high and low risk groups is sought by spreading the financial burden for plan solvency across an entire population. Provincial plan revenues derive from general taxes, special earmarked taxes, premiums or a combination of the above. The federal contribution under prevailing fiscal agreements is calculated at roughly 50~o of each province's costs for specified hospital and medical services [1]. Health insurance plans are social in their aims since they represent part of a broader movement in industrialized societies to extend certain basic social rights to progressively wider strata of the population. The programs are designed to have a direct impact on the welfare of the nation's citizens by eliminating the influence of income as a restraining factor on desire for health care. Implicit in this process is a concept of health care as a social right which should be equally available to all regardless of ability to pay and which comprises an essential component in the status of citizenship [2]. The full implications for public policy of government health insurance measures are still evolving. Two emergent trends seem especially significant. First, through the medium of public accountability for the costs of health care. governments have found themselves assuming progressively greater responsibility for the organization and quality of health services. Second, from the premise that the goals of public policy with respect to health basurance should be directed towards the welfare of all groups, an emergent concern with the concept of social equity in health care has evolved. John Munro, a former Minister of National Health and Welfare in Canada, gave explicit recognition to these forces when he stated of government's expanded role in health affairs, We must ensure the right care to the right person at the right time in the right place and at the right