Edward Alan Miller - Block Granting Medicaid: A Model for 21st Century Health Reform?

This is a wonderful in-depth case study of Rhode Islands Medicaid Waiver debate. Every few years the debate about block granting Medicaid remerges. It is only with details found within that we can enter into those debates with a clear idea of its implications. We should thank Miller for such an insightful analysis.

Colleen Grogan, University of Chicago

In this book, one of the nations foremost experts on Medicaid and state health policy dissects the challenging process of translating a bold idea into a workable new system of care for Rhode Islands most vulnerable citizens. It delivers bad news for those who would reflexively put all states on fixed block grants for their Medicaid programs. It reminds reformers of all persuasions of how important leadership, expertise, and outreach to community stakeholders are to producing even modest improvements in vital services and system efficiency.

Tom Oliver, University of Wisconsin-Madison

Medicaid is the largest grant-in-aid program in the United States. As such, reform in this area provides a unique opportunity to study the intersection between federal and state policy making in an area characterized by substantial uncertainty deriving from the lingering effects of the Great Recession, ongoing debate over the federal budget, and implementation of the Patient Protection and Affordable Care Act. Invariably, states reform the way health care is delivered, regulated, and financed within broader parameters established by federal statutes and regulations. It is critical that effective strategies be put into place at each level of government if both current and future health and long-term care reform efforts are to have their greatest chances at success. Rhode Island is the first state to receive permission to operate its entire Medicaid program under a global cap. As a consequence, it has entered the national consciousness as a key data point potentially supporting the block grant approach to Medicaid reform.

In this book, Edward Alan Miller draws on Rhode Islands experiences to assess conservatives claims that the states Global Consumer Choice Compact Medicaid Waiver represents a national model for Medicaid reform. Evidence gathered from archival sources and in-depth interviews with key stakeholders exposes factors that facilitated and impeded the design and implementation of Rhode Islands Global Waiver. These factors, in turn, suggest broader lessons for the Medicaid block grant debate and health and long-term care reform more generally; that, for example, Rhode Islands experience does not support block granting Medicaid while highlighting the role of stakeholder engagement, provider capacity, and federal fiscal support in the implementation process.

By providing a sophisticated understanding of factors enhancing or hindering state health reform, this book will contribute to improvements in the development and administration of policy development at both the state and federal levels.

Edward Alan Miller is associate professor in the Departments of Gerontology and Public Policy and Fellow in the Gerontology Institute at the University of Massachusetts Boston, and adjunct associate professor in the Departments of Political Science and Health Services, Policy and Practice at Brown University. He is a Fellow of the Social Research, Policy and Practice Section of the Gerontological Society of America.

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7 Block Granting Medicaid

A Model for 21st-Century Health Reform?

Edward Alan Miller

A Model for 21st Century Health Reform?

Edward Alan Miller

First published 2014

by Routledge
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and by Routledge
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2014 Taylor & Francis

The right of Edward Alan Miller to be identified as author of this work has been asserted by him/her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

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Library of Congress Cataloging-in-Publication Data
Miller, Edward Alan.
Block granting Medicaid: a model for 21st century health reform? / Edward Alan Miller.
pages cm (Routledge research in public administration and public policy volume 7)
1. MedicaidFinanceMathematical models. 2. Health care reform United States21st century. 3. Medical care, Cost ofUnited States Mathematical models. 4. MedicaidRhode Island. I. Title.
RA412.4.M55 2013
368.4'200973dc23
2013022304

ISBN: 978-0-415-72062-5 (hbk)

ISBN: 978-1-315-86688-8 (ebk)

Typeset in Sabon
by Apex CoVantage, LLC

The author would like to thank the Robert Wood Johnson Foundation for invaluable financial support (grant #64214). The author would also like to thank the staff at the State Health Access Data Assistance Center (SHA-DAC), but especially Caroline Au-Yeung, Elizabeth Lukanen, and Lynn Blewett for their efforts administering the grant. The author would further like to thank the students and colleagues at the University of Massachusetts Boston and Brown University who contributed to the research that informed this work. These individuals include Divya Samuel, Susan Allen, Amal Trivedi, Vincent Mor, Corina Ronneberg, Emily Gadbois, and Pamela Nadash. Views expressed belong to the author only. No other entity or individual is responsible for the content contained herein.

Medicaid is the jointly-funded federal-state health insurance program for the poor and disabled. Although administered by the states, the federal government matches state Medicaid spending at a rate determined by the Federal Medical Assistance Percentage (FMAP), which currently ranges from 50% to 73.4% and is dependent on state per capita income (Snyder et al. November 2012). Concomitant with provisions in the Patient Protection and Affordable Care Act of 2010 expanding Medicaid coverage to millions more Americans and a U.S. Supreme Court decision making this expansion a state option, conservative opinion leaders and Republicans officials have sought program retrenchment. This policy priority is most prominently reflected in revival of the block grant approach to Medicaid reform by Republican Congressman, House Budget Committee Chair and former Vice Presidential candidate Paul Ryans Fiscal Year (FY) 2012, 2013, and 2014 House budget proposals (Ryan 2011, 2012, 2013). In exchange for virtually unlimited flexibility administering Medicaid, the block grant approach would provide states with a fixed, upfront federal allotment or block grant that would no longer require a state match. All three House budget proposals which, in addition to block granting Medicaid would repeal the Affordable Care Act, passed the Republican controlled House of Representatives along a party line vote. Indeed, the Republican House has voted to repeal the Affordable Care Act 40 times and counting, with, for example, a 229 to 195 vote on May 16, 2013, drawing just two Democrats (Fahrenthold May 16, 2013).