Medicaid, Managed Care, and the Mission for the Poor

Medicaid has financed care for the poor for five decades. During that time it has balanced two important missions: providing for the particular health needs of the poor, and mainstreaming care for the poor. These roles have been consistent as all insurance payors—public and private—have shifted away from passively funding fragmented care to actively supporting patient-centered coordinated care. But the health needs of the poor go beyond medical interventions; the health status of the poor depends on the provision of social services to address social determinants of health, including housing, nutrition, and employment training services. Unlike non-poor insureds, Medicaid beneficiaries rely uniquely on third-party support for access to both medical care and social services. This need for a focus on funding for social as well as medical care distinguishes the circumstances of the poor, and argues for a Medicaid focus not on mimicking middle-class health insurance programs, but rather on the particular needs of the poor. These particular needs should be coordinated and funded through Medicaid Accountable Care Organizations and interagency cooperation through Health in All Policies orientations. While it is appropriate from Medicaid programs—including managed care programs—to ease the transition of beneficiaries between Medicaid and commercial insurance, it is more important than ever for Medicaid to have a particular focus on its core mission of serving the most vulnerable. As the Centers for Medicare and Medicaid Services agency turns to the regulation of Medicaid managed care programs, it should leave states sufficient flexibility to encourage innovative programs for the poor, and avoid overvaluing efforts to make Medicaid more like mainstream commercial insurance

Mission and Markets in Health Care: Protecting Essential Community Providers for the Poor

Should government protect mission-driven providers in the shift to Medicaid managed care? In part, the answer to this question turns on the statutory purposes of Medicaid as both a vehicle for providing an opportunity for the poor to enter the medical mainstream, and as a program to provide medical care in a setting that includes a wide variety of culturally appropriate social services. The answer also turns in part on an economic and public policy analysis of the performance of these mission-driven providers in comparison with their for-profit counterparts. Part I of this article will describe the complex mission of Medicaid, as a program that on the one hand integrates the poor into the mainstream of health care, and on the other hand provides enhanced, supplementary or remedial care to a population with different and greater needs. Part I concludes that legislative intent is insufficiently clear to determine the fate of mission-driven providers. Rather, their fate must depend on economic and public policy analysis of their effect on Medicaid beneficiaries\u27 health care. Part II will describe the developing Medicaid managed care system, and the complex, largely informal mechanisms by which essential community providers achieve some limited insulation from competitive forces. Part III will argue that regulatorily mandated inclusion of essential community providers in Medicaid managed care networks is appropriate for three reasons. First, mission-driven providers have in the past and are likely in the future to be willing and able to cost-shift, providing necessary care to the poor uninsured. Second, information asymmetries that plague the Medicaid managed-care market can be ameliorated to some extent by affording special status to historic Medicaid providers. Third, the nonprofit essential community providers\u27 reliance on debt financing and donations renders their capital less mobile than that of their for-profits competitors, who normally rely on equity markets. This capital immobility lends stability to the provider network for the vulnerable Medicaid population in the inevitable event of significant funding contraction

Jacobi multipliers, non-local symmetries and nonlinear oscillators

Constants of motion, Lagrangians and Hamiltonians admitted by a family of relevant nonlinear oscillators are derived using a geometric formalism. The theory of the Jacobi last multiplier allows us to find Lagrangian descriptions and constants of the motion. An application of the jet bundle formulation of symmetries of differential equations is presented in the second part of the paper. After a short review of the general formalism, the particular case of non-local symmetries is studied in detail by making use of an extended formalism. The theory is related to some results previously obtained by Krasil'shchi, Vinogradov and coworkers. Finally the existence of non-local symmetries for such two nonlinear oscillators is proved.Comment: 20 page