Discussion: Federalism’s Impact on Policy

Gluck et. al., (2018) discussed several states including Indiana and Connecticut who demonstrated the appearance of not opting in (to expansion) but were actually working behind the scenes (with HHS) to accomplish expansion goals all the while negotiating federal monies and support. An example of how Federalism in health care may allow for shifting responsibility. This scenario demonstrates possible disadvantages of duplication as several states were manipulating the situation for their own gains. It does make sense however, that the federal government be involved in health policy development.  The Congress and Senate are made up of leaders from across the U.S. and are representative of their States.  One would hope they have the best interest of their constituents in mind.

References

Butler, S. M. (2019). Federalism as an Antidote to Polarization Over Health Care Policy. JAMA, 322(12), 1131–1132. https://doi.org/10.1001/jama.2019.14114

Gluck, A. R., & Huberfeld, N. (2018). What Is Federalism in Healthcare For? Stanford Law Review, 70(6), 1689–1803.

Huberfeld, N. (2019). Epilogue: Health Care, Federalism, and Democratic Values. American Journal of Law & Medicine, 45(2–3), 247–252. https://doi.org/10.1177/0098858819860612

Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: Discussion: Federalism’s Impact on Policy

American Federalism in Practice is an original and vital contribution to our understanding of contemporary health policy. It also

illustrates how public policy is debated, formulated, and implemented in today’s overheated political environment. Health care reform is perhaps the most divisive public policy issue facing the United States today (Doonan, 2013). The health policy is an intergovernmental relationship between the federal and state. They both work together to shape public policy by creating, formulating, and implementing three of the most critical health policy initiatives in health care today (Doonan, 2013). At the state level, the Children’s Health Insurance Program (CHIP) and the Health Insurance Portability and Accountability Act (HIPAA), both passed by the U.S. Congress, and the Massachusetts health care reform program was developed and implemented under federal government waiver authority (Doonan, 2013).  Affordable Care Act.’ Health policymaking is entangled in a complex web of shared, overlapping, and competing power relationships among different levels of government. Understanding federal-state interactions, how they vary, and the reasons for such variation is essential to grasping the ultimate impact of federalism on programs and policy (Doonan, 2013).

The State Children’s Health Insurance Program (CHIP) is a means-tested program that provides health coverage to targeted low-income children and pregnant women in families with annual income above Medicaid eligibility levels but has no health insurance. The federal government and the states jointly finance CHIP, and the conditions are responsible for administering CHIP. The federal government’s share of CHIP expenditures includes services and administration (Mitchell, 2018). The federal appropriation for CHIP is provided in the statute from this federal appropriation. States receive CHIP allotments, the federal funds allocated to each state, and the territories for the federal share of their CHIP expenditures. In addition, if a state has a shortfall in federal CHIP funding, there are a few sources of shortfall funding, such as the Child Enrollment Contingency Fund, redistribution funds, and Medicaid funds (Mitchell, 2018).

The government’s responsibility to protect and advance the interests of society includes the delivery of high-quality health care. Because the market alone cannot ensure all Americans access to quality health care, the government must preserve the interests of its citizens by supplementing the market where there are gaps and regulating the market where there is inefficiency or unfairness (Gaynor, 2014). The ultimate goal must be providing high-quality care that will require strong partnerships between federal, state, and local governments and the private sector.

Reference

Competition policy in health care markets: navigating the enforcement and policy maze.

Gaynor M.Health Aff (Millwood). 2014 Jun;33(6):1088-93. DOI: 10.1377/hlthaff.2014.0333. Epub 2014 May 19.PMID: 24841882

Michael Doonan. (2013). American Federalism in Practice : The Formulation and        Implementation of Contemporary Health Policy. Brookings Institution Press.

Mitchell, A. (2018). Federal Financing for the State Children’s Health Insurance Program (CHIP). Congressional Research Service: Report, 1–12.

Thanks so much for your insightful post this week regarding The Children’s Health Insurance Program (CHIP) and the government’s responsibility to protect the interest of society, specifically those that are disadvantaged, impoverished, or vulnerable. The SHIP program serves a subset of the population that is often ignored. Those who make too much money to qualify for Medicaid but make just barely above the poverty line preventing them from purchasing private insurance or paying for health care out of pocket. In a Cochrane review, I looked at this week the authors Jia et al. (2022), examined the techniques used for informing individuals who qualify for assistance. What they found is that the case managers who worked with this population were more likely to offer information to the entire family about additional insurance plans if the individuals had children. So the CHIP program is making a difference for more people than just uninsured children. Additionally, Ghadder et al. (2018), discussed the importance of making sure that those individuals who are receiving this information get additional help from a health literacy perspective to understand the different options available to them and make decisions for themselves and their children that are best for them. The reason backing by two separate branches of government is so important regarding health care issues is that the funding and power to influence its success is more likely. The CHIP program is a testimony to that success.

References:

Ghaddar, S., Byun, J., & Krishnaswami, J. (2018). Health insurance literacy and awareness of the Affordable Care Act in a vulnerable Hispanic population. Patient Education and Counseling, 101(12), 2233–2240. https://doi.org/10.1016/j.pec.2018.08.033

Jia, Liying, Beibei Yuan, Fei Huang, Ying Lu, Paul Garner, Qingyue Meng, and Qingyue Meng. 2022. “Strategies for Expanding Health Insurance Coverage in Vulnerable Populations.” Cochrane Database of Systematic Reviews, no. 11. Accessed April 22. https://search.ebscohost.com/login.aspx?direct=true&AuthType=shib&db=chh&AN=CD008194&site=eds-live&scope=site.

Historically, the elderly and the disabled receive long-term care in institutionally setting because Home and Community Base Care services (HCBS) were less available. However, in the 1980s, an amended federal law passed a federal-state Medicaid waiver authority for states to expand HCBS services to cover individuals at risk for institutionalized care (Musumeci et al., 2020). These individuals will receive broader services that were not allowed by Medicaid state plans. The HCBS 1915 (c) waivers authorized states to provide targeted services to populations such as seniors, people with physical or developmental disabilities, and individuals with specific conditions such as HIV/AIDS or traumatic brain injuries(Merryman et al., 2015). Essential to note every state’s eligibility requirement and criteria are different; however, HCBS waivers are limited to three years but may extend five years for those dually enrolled in Medicaid and Medicare (Merryman et al., 2015).

In response to the COVID-19 pandemic, President Biden signed the American Rescue Plan Act (ARPA), which provides $1.9 trillion for several provisions to include in the pandemic relief package (Miller & Beauregard, 2022). This legislation will significantly impact state and federal health policies and programs, such as federal funding for state Medicaid spending on HCBS. The ARPA will provide a one time10% increase in federal matching payment to states’ HCBS to supplement state expenditure which would only be available for a year(Miller & Beauregard, 2022. Therefore, states would have the flexibility in overlapping with federal policies targeting HCBS to specific populations. Nonetheless, the ARPA ensures that states benefit from the federal investment for HCBS to achieve the best outcomes for Medicaid beneficiaries to receive high-quality, cost-effective, person-centered care in their home (Watts et al., 2020).

Duplication Advantages & Disadvantages

The advantage to the federal-state funding of HCBS is that it provides states with good flexibility to utilize these funds that align with the priorities of local policies (Musumeci et al., 2020). As a result, states will be able to enhance their HCBS models (Watts et al., 2020). Furthermore, states taking advantage of access to federal funds will also address the shift in demand for healthcare needs because of COVID public health emergencies (Miller & Beauregard, 2022). On the other hand, states will need to determine how they will sustain this investment once the expiration of federal matching.

Implications of Federalism

Nevertheless, the enactment of the American Rescue Plan Act (ARPA) with the inclusion of increasing state funds to HCBS foreshadowed the United States as a federalist system. Oversight of health policy decisions responsibility is shared among federal and state in areas of administration and funding. The state and federal are jointly responsible for the healthcare financing for the health and long-term care of low-income populations with the appropriate balancing of these responsibilities (Collins, & Lambrew, J2019). However, federalism contributes to the fragmentation of the U.S healthcare system due to the different financing and service delivery modes, leading to duplication of services.

Federal Government Involvement in Healthcare Policymaking

According to Bialik (2018), the Pew research reported that 60% of American believe that the federal government should be responsible for ensuring healthcare coverage for all Americans. Essentially, the federal government plays a central role in the oversight and shaping of the American health care arena to develop policies that support cost-effective quality programs for the population’s health needs. Therefore, the federal government should maximize its involvement given its unique position as regulators, healthcare purchasers, sponsors of applied healthcare research, healthcare provider education, and healthcare providers (Crowley et al., 2020). Furthermore, federal leadership is a crucial stakeholder having extensive healthcare programs and market influence, which helps acquire sustainable healthcare reform and better quality and value in healthcare (Gluck & Huberfeld, 2018). For instance, the federal government has been a critical player in establishing Medicare and Medicaid to ensure access to insurance coverage for a large segment of the population, legislation for employer-sponsored health insurance, and expanded federal healthcare programs (Collins & Lambrew, 2019 ). Currently, the federal leadership plays a pivotal role in the Affordable Care Act by expanding health insurance coverage to the uninsured. Hence, the federal government plays an essential role in promoting healthcare services that contribute to healthcare efficiency and saving, so the federal government should maintain a central role in healthcare policymaking.

References

Bialik, K. (2018). More Americans say government should ensure health care coverage. Universal Health Care, 94.

Collins, S. R., & Lambrew, J. M. (2019). Federalism, the Affordable Care Act, and health reform in the 2020 election. The Commonwealth Fund.

Crowley, R., Daniel, H., Cooney, T. G., Engel, L. S., & Health and Public Policy Committee of the American College of Physicians*. (2020). Envisioning a better US health care system for all: coverage and cost of care. Annals of Internal Medicine, 172(2_Supplement), S7-S32.

Gluck, A. R., & Huberfeld, N. (2018). What is federalism in healthcare for. Stan. L. Rev., 70, 1689.

Merryman, M. B., Miller, N. A., Shockley, E., Eskow, K. G., & Chasson, G. S. (2015). State adoption of Medicaid 1915 (c) waivers for children and youth with autism spectrum disorder. Disability and health journal, 8(3), 443-451.

Miller, E. A., & Beauregard, L. K. (2022). Enhancing Federal Revenue under the American Rescue Plan Act: An Opportunity to Bolster State Medicaid Home and Community-Based Services Programs. Journal of Aging & Social Policy, 1-15.

Musumeci, M., Watts, M. O., & Chidambaram, P. (2020). Key state policy choices about Medicaid home and community-based services. Kaiser Family Foundation.

Watts, M. O., Musumeci, M., & Chidambaram, P. (2020). Medicaid home and community-based services enrollment and spending. Kaiser Fam Found.