Explaining Incremental and Non-Incremental Change: Medicaid Nursing Facility Reimbursement Policy, 1980-98

Abstract

Political scientists have long distinguished between incremental and non-incremental policymaking. In this study, I illustrate the relevance of this distinction for comparative state policy research by modeling both incremental and non-incremental change in the same policy area: Medicaid nursing facility reimbursement. I use mixed-modeling techniques to model incremental year-to-year changes in per diem rates and payments per recipient and event history analysis and ordered logit to model non-incremental comprehensive innovation in this policy area. My results indicate that federal action prompted non-incremental change in capital reimbursement policy by limiting state discretion over incremental year-to-year spending decisions.

The Role of the Media in Agenda Setting: The Case of Long-Term Care Rebalancing

“…It is consistent with surveys revealing strong preferences among elders to remain in the least restrictive setting possible, as long as possible, typically at home rather than in a nursing home, should the need for LTSS arise (AARP, 2003; “Los Angeles Times poll,” 2009). It is also consistent with prior research revealing an association between interest group activity on behalf of the elderly and long-term care policy outcomes at the state level (Harrington, Mullan, & Carrillo, 2004; Miller, 2006). …”

The Affordable Care Act and Long-Term Care: Marginal Advancement on the Status Quo

“…This is due, in part, to the nursing home industry's status as one of the most powerful lobbies in state government (Miller, 2006(Miller, , 2008. Nursing homes are especially forceful in influencing policy due to heavy dependence on Medicaid for revenue, with such activity being associated with increased likelihood of adoption of favorable policies affecting nursing home reimbursement, eligibility, and enforcement (Miller, 2006(Miller, , 2008.…”

Improving Direct-Care Compensation in Nursing Homes: Medicaid Wage Pass-Through Adoption, 1999–2004

“…Although several studies have examined the correlates of Medicaid nursing home reimbursement, most have done so with respect to overall levels of payment or provisions intended to improve cost efficiency, access to care, equity in provider payment, and service capacity (Miller 2006a, 2006b; Miller and Wang 2009a, 2009b; Swan, Harrington, and Pickard 2000; Swan et al 1997, 2001). None have done so with respect to incentives built into state payment systems to improve quality.…”

“…In the Medicaid nursing home reimbursement area, this includes case-mix adjustment, fair rental reimbursement, and provider taxes (Miller 2006b; Miller and Wang 2009a, 2009b). It is clear from the distribution of WPT adoption in our data set that most states, most of the time, decide annually whether to implement or keep these programs.…”

“…Although WPT programs are the primary means through which states have sought to improve staffing and, in turn, quality, no systematic empirical research has been conducted to examine the comparative influence of external and internal factors on the adoption decision. That WPT adoption may be related to such factors is reflected in prior research identifying significant associations between political, economic, programmatic, interstate, and federal-level factors with policies affecting Medicaid generally and nursing home reimbursement specifically (Allen, Pettus, and Haider-Markel 2004; Barrilleaux and Miller 1988; Davidson 1978; Grogan 1999; Harrington, Mullan, and Carrillo 2004; Harrington, Carrillo, et al 2000; Kane et al 1998; Kousser 2002; Miller 2005, 2006a, 2006b; Miller and Wang 2009a, 2009b; Pracht 2007; Swan, Harrington, and Pickard 2000; Swan et al 1997, 2001). …”