Medicaid Payment and Delivery Reform: Insights from Managed Care Plan Leaders in Medicaid Expansion States

Issue: Managed care organizations (MCOs) are integral to Medicaid payment and delivery reform efforts. In states that expanded Medicaid eligibility under the Affordable Care Act, MCOs have experienced a surge in enrollment of adults with complex needs.Goal: To understand MCO experiences in Medicaid expansion states and learn about innovations related to access to care, care delivery, payment, and integration of health and social services to address nonmedical needs.Methods: Interviews with leaders of 17 MCOs in 10 states that have seen large Medicaid enrollment growth and have undertaken payment and delivery reforms.Findings and Conclusions: MCO leaders regard their ability to enroll and serve the Medicaid expansion populations as a signal achievement. They have focused on identifying and helping high-risk populations and addressing the social determinants of health. MCOs are testing value-based payment strategies that link payment with performance and are increasingly focused on engaging patients in their care. Leaders report common challenges: setting appropriate payment rates; managing members whose needs differ from traditional Medicaid beneficiaries; ensuring access to specialty care; and effectively implementing payment reform and practice transformation. All point to the need for a stable policy environment and a strong working relationship with state Medicaid agencies

Medicaid and access to the courts

The Medicaid program is grounded in a statute that is one of the most complex of all federal laws. An insurer of more than 60 million people — and poised to begin serving 16 million more by 2019 — Medicaid will be reexamined this year, in all its legal complexities, by the U.S. Supreme Court, which has agreed to hear California\u27s appeal in the case Maxwell-Jolly v. Independent Living Center of Southern California. The Court\u27s ruling could fundamentally alter states\u27 accountability to beneficiaries and providers when their official conduct allegedly violates Medicaid\u27s essential federal requirements

Abortion Provisions in the Senate Managers Amendment

An assessment on the potential industry effects of the abortion provisions in the Senate Managers Amendment made available on December 18, 2009

An overview of the administration\u27s ACO policy: Opportunities and challenges

For nearly a century, proponents of health reform have advocated for greater clinical integration to improve quality, promote efficiencies, and control costs. A seminal 1932 report issued by the Committee on the Costs of Medical Care called for the provision of care through group practice arrangements as part of a broader set of recommendations that included universal coverage, extension of public health services to the entire population, and a major investment in health professions education. Resistance to its findings was a key factor in convincing the Roosevelt Administration to abandon national health insurance in the original Social Security Act

Olmstead v L.C.: Federal Implementation Guidelines, and Analysis of Recent Cases Regarding Medicaid Coverage of Long Term Care Services for Persons with Disabilities

This analysis reviews the key elements of the United States Supreme Court\u27s 1999 decision in Olmstead v L.C. as well as Federal implementation guidelines issued by the United States Department and Human Services. The Olmstead decision interprets the Americans with Disabilities Act ( ADA, PL 101-336), whose requirements apply to the use of all public funds. However, Medicaid represents the single largest source of public funding for both institutional and non-institutional services for persons with disabilities. As a result, when states expend Medicaid funds on care for persons with disabilities, two independent sets of legal requirements are triggered: those contained in the ADA, and those included in Federal Medicaid law. Therefore, this analysis also reviews recent judicial decisions concerning Medicaid coverage requirements in the case of institutional and noninstitutional for beneficiaries with disabilities

Clash of the Titans: Medicaid Meets Private Health Insurance

Throughout its first forty-eight years of life, the federal Medicaid statute lacked a viable insurance pathway for most low-income adults\u27 ineligible for employer-sponsored coverage. In what is arguably the most important public health achievement since the enactment of Medicare and Medicaid fifty years ago, the Patient Protection and Affordable Care Act (ACA) fundamentally alters this picture. Building on earlier breakthroughs for children, the ACA restructures Medicaid to cover poor adults and juxtaposes its new architecture against an affordable and accessible private insurance market for people ineligible for employer-sponsored or government insurance

A dose of reality: Assessing the Federal Trade Commission/Department of Justice report in an uninsured, underserved, and vulnerable population context

Despite the size of their report, the Federal Trade Commission and Department of Justice pay virtually no attention to tens of millions of uninsured and underinsured persons. By focusing on an increasingly rarified group of health care customers—healthy, affluent, and highly insured—the report takes on an untethered quality, with only the slightest tip of the hat to its own limitations. Furthermore, the report overstates the extent of legal constraints on the market, in particular, the degree to which the market is free to select its customers and tailor its goods and services to the best risks. By miscasting the legal context of the American health care system, the report ultimately undermines much of its potential value

A broader regulatory scheme -- The constitutionality of health care reform

The fundamental goal of the ACA is no less than the preservation of the U.S. health care system. In a country that depends on health insurance to finance care, preservation cannot happen without a comprehensive regulatory scheme that reaches from coast to coast and sets the minimum rules of market entry and operation for health insurers. The glide path to this new system is long and complex, but the law\u27s end point is clear and visionary, and its constitutionality--at least in this first round--is incontrovertible