Medicare, Medicaid and the Deficit Debate

Examines 2000-10 Medicare and Medicaid expenditures; projections for 2011-20 from the Centers for Medicare and Medicaid Services and the Congressional Budget Office; contributing factors, including enrollment growth; and proposals for curbing spending

Have Recent Budget Policies Contributed to Long-Run Fiscal Stability?

Examines developments in budget policies since January 2010; the president's 2011 budget, including economic stimulus and tax and spending policies; congressional action; and issues for health reform. Considers their effect on long-term sustainability

Projecting the Impact of the Money Follows the Person Program on Idaho Medicaid Long-Term Care Expenditures

Background: It is well established that access to home and community-based services (HCBS) as an alternative to institutional long-term care (LTC) leads to better health outcomes. Because Medicaid is the primary payer for formal LTC services, changes in Medicaid policies favoring access to HCBS play a crucial role in “rebalancing” the nation\u27s LTC delivery system. Prior research indicates that expanding Medicaid HCBS may result in lower per patient expenditures. A key part of Medicaid\u27s rebalancing effort is the recently expanded Money Follows the Person (MFP) program, whereby the federal government offers enhanced match funds to assist state Medicaid programs in transitioning institutionalized LTC patients to the community. Problem: Despite the potential benefits of increasing access to Medicaid HCBS, in this time of budget cuts, policymakers may be resistant to expanding such services. Method/Data: A model to project the impact of MFP on Idaho’s Medicaid expenditures over 10 years was designed using established cost projection methodologies, Medicaid Statistical Information System (MSIS) data, and pertinent Medicaid policies. The model was then applied to Idaho’s MFP program from state fiscal year (SFY) 2011 to 2020 to compare projected Medicaid expenditures in the absence of MFP with such projected expenditures under low and high model projections of how effective the MFP program will be in transitioning institutionalized LTC patients to the community. Results: Baseline projections indicate that Idaho Medicaid will spend approximately $6.8 billion on LTC between SFY 2011 and SFY 2020. High and low model projections indicate that, after accounting for estimated increased acute care expenditures, Idaho Medicaid will be$16.5-32.5 million more cost effective over ten years with MFP. Projected efficiencies may be partially offset by the “moral hazard” of expanding HCBS. Discussion: Implementing the MFP Program in Idaho is projected to reduce overall Idaho Medicaid expenditures in coming years. Such reductions, however, will be greater if Medicaid acute care expenditures for Medicaid HCBS recipients can be reduced. Accordingly, coordination of cost-effective LTC and acute care in the community is crucial to reducing Medicaid LTC expenditures in coming years

Starting on the Path to a High Performance Health System: Analysis of Health System Reform Provisions of Reform Bills in the House of Representatives and Senate

Compares the reform bills' reform provisions, with a focus on closing the coverage gap by creating an insurance exchange of public and private plans, strengthening Medicare, and expanding Medicaid. Examines implications for the budget and coverage rates

Debt Management: Treasury's Cash Management Challenges and Timing of Payments to Medicare Private Plans

A letter report issued by the Government Accountability Office with an abstract that begins "A timing difference between cash in- and outflows poses challenges for the Department of the Treasury. Increased volatility of monthly cash flows may lead to unexpected short-term debt issuance and hence increased borrowing. While Social Security payments made at the start of the month will diminish gradually in coming years, start-of month payments to Medicare plan sponsors for Medicare Advantage and Part D benefits are projected to grow. As requested, this report (1) describes how Treasury, the Centers for Medicare & Medicaid Services (CMS), and plan sponsors operate under the current payment schedule; (2) identifies timing options; and (3) describes potential implications for Treasury, CMS, and Medicare. GAO analyzed Treasury cash flows, and interviewed Treasury, CMS officials, and plan sponsor representatives.

Medicare: A Primer 2009

Provides an overview of Medicare, including information on eligibility, enrollee characteristics, services covered, prescription drug coverage, supplemental insurance, costs and expenditures, and financing challenges. Lists cost-sharing requirements

Patient Protection and Affordable Care Act: Effect on Long-Term Federal Budget Outlook Largely Depends on Whether Cost Containment Sustained

A letter report issued by the Government Accountability Office with an abstract that begins "The effect of the Patient Protection and Affordable Care Act (PPACA), enacted in March 2010, on the long-term fiscal outlook depends largely on whether elements in PPACA designed to control cost growth are sustained. There was notable improvement in the longer-term outlook after the enactment of PPACA under GAO's Fall 2010 Baseline Extended simulation, which assumes both the expansion of health care coverage and the full implementation and effectiveness of the cost-containment provisions over the entire 75-year simulation period. However, the federal budget remains on an unsustainable path. Further, questions about the implementation and sustainability of these provisions have been raised by the Centers for Medicare & Medicaid Services' Office of the Actuary and others, due in part to challenges in sustaining increased health care productivity. The Fall 2010 Alternative simulation assumed cost containment mechanisms specified in PPACA were phased out over time while the additional costs associated with expanding federal health care coverage remained. Under these assumptions, the long-term outlook worsened slightly compared to the pre-PPACA January 2010 simulation.

The Medicare Part D Coverage Gap: Costs and Consequences in 2007

Analyzes data on Medicare Part D enrollees who reached the coverage gap and had to pay the full cost until they qualified for catastrophic coverage, who then stopped taking their medications or bought cheaper ones, and who received catastrophic coverage

Budgeting on Autopilot: Do Sequestration and the Independent Payment Advisory Board Lock-in Status Quo Majority Advantage?

Amid deeply polarized discourse over spending choices, Congress has resorted frequently to the particular device of binding “automatic” cuts, a form of Congressional precommitment whereby Congress takes steps at time one with the intention of changing the likelihood it will make certain choices at time two. I argue that these devices are dis-ingenuous in two ways. First, legal analysis shows they do not actually bind Congress, even as they claim to. To the extent they have any traction, it is by appealing to our nor-mative reluctance to flout pre-existing rules, which, in other words, means they work by invoking the ideology of “legalism.” Legalism, as defined by political theorist Judith Shklar, is the norm privileging rule-following, which is seen as “neutral,” over other forms of decision-making, which are “political.” However, in the realm of guns-or-butter spend-ing choices, the invocation of legalism is disingenuous, since these decisions are deeply politically contested. Not only do they purport to bind when they don’t, these Congres-sional precommitments also purport to be neutral when they are politically purposive ef-forts to lock-in preferences. This article analyzes and debunks the three main methods of precommitment, and then applies those findings to sequestration and the Independent Payment Advisory Board from the health reform law, to show what happens when we try to make these kinds of political decisions by legalistic “automatic cuts” which deceptively purport to be a more rule-bound, “neutral” approach. I find that these precommitments amplify the advantages of status-quo majorities over minorities, while undercutting the values of transparency and coherence

The effects of state minimum staffing standards on staffing, quality of care, and financial performance in nursing homes

This dissertation attempts to provide a comprehensive understanding about the impacts of state minimum staffing standards and to determine unbiased estimates of the effect of staffing on quality of nursing home care. Specifically, by exploiting differences in the timing of staffing standard changes for the 50 states and the District of Columbia from 1998 to 2001, this study conducts three empirical analyses to examine (1) the total effects of staffing standards on staffing choices and on quality of care, (2) the total effect of staffing standards on financial performance, and (3) the underlying (causal) relationship between staffing and quality of care. The major findings are as follows: (1) Increases in staffing standards matter particularly for the subset of nursing homes with staffing level previously below or close to new standards, whereas the results show consistent beneficial effects for the rate of restraint use and the number of total deficiencies at all types of facilities. (2) Increases in staffing standards have significant negative impacts on total margin at nonprofit facilities with relatively low staffing. (3) When endogeneity of staffing is taken into account, the results support the persistent beneficial effects of increasing total staff hours on the onset of pressure sores, contractures, and catheter use. The analyses performed in this dissertation are particularly relevant to the era of growth in the aged population and provides important policy implications. Structural differences in nursing home behavior in response to increased staffing standards suggest that future policy should be developed by emphasizing on stragetic planning and operative management of scarce labor resources to achieve both better quality and greater efficiency. In order to achieve the benefits of mandatory staffing standards, the federal and state governments should determine the additional costs and develop a plan to adequately fund the required increases in staffing levels. The monitoring and enforcement of federal and state laws and regulations are necessary. Lastly, the findings suggest that differences in financial performance may result in differences in quality produced and vice versa. An integrative perspective which explores the relationship between quality and financial performance may be insightful in the future research