Medicaid Long-Term Care: State Variation and the Intergovernmental Lobby

Abstract

Medicaid is vastly more important than Medicare or private insurance in funding long-term care (LTC). However, states vary tremendously in their commitment to Medicaid LTC. This article advances knowledge of the origins, nature, and implications of this variation. After examining the degree of variation in state spending on Medicaid LTC, we show how federal policy has over the past fifty years steadily increased state discretion to shape these services. This decentralization largely reflects the potency of the intergovernmental lobby-governors and other state officials-in influencing federal policy. While fueling state variation, the intergovernmental lobby has also provided valuable political support that has helped Medicaid grow and resist retrenchment. After considering policy options that could mitigate Medicaid LTC inequities rooted in state differences, we assess how the catalytic forces that have fueled growth in Medicaid LTC may be insufficient to protect the program from future erosion.

Death, long-term nursing home placement, and impoverishment after recurrent myocardial infarction

“…Although administrative claims data do not contain direct measurements of quality of life or other patient-reported outcomes, claims data can allow for assessment of other outcomes of importance to patients including long-term nursing home placement and new enrollment in programs for impoverished individuals, as in this study. The long-term nursing home placement and impoverishment outcomes are interrelated; many older adults living in long-term care settings enroll in Medicaid, a state/federal health insurance program for economically disadvantaged individuals, after depleting their assets paying for residential care [16] . In both the recurrent MI cohort and matched controls who experienced an initial MI, death was by far the most common of the outcomes examined, with nearly half of those with recurrent MI and 1 in 6 of those with an initial MI dying in the first year of follow-up.…”

“…We used Cox proportional hazard models with the Breslow method for tie handling to estimate hazard ratios (HR) and 95% confidence intervals (CI) for death, long-term nursing home placement, and impoverishment, separately, among beneficiaries in the recurrent MI cohort compared to controls. As the Medicaid policies related to eligibility, including “spending-down” savings to obtain eligibility, and benefits vary by state [16] , we allowed the baseline hazards (i.e., the rates of death, long-term nursing home placement, and impoverishment) to vary across states. The first model was unadjusted.…”

The effect of political control on financial performance, structure, and outcomes of US nursing homes

“…However, with increasing state discretion over the past 50 years, state governments are now the most important decision makers with regard to eligibility, reimbursement, and the provision of care in Medicaid long-term care programs. 18 Changes in Medicaid regulations are shaped at the state level through the legislative process. In all US states except Nebraska,* the legislative procedure resembles the federal process.…”

“…The state programs have to conform to federal guidelines in order for the state to receive matching funds and grants. However, with increasing state discretion over the past 50 years, state governments are now the most important decision makers with regard to eligibility, reimbursement, and the provision of care in Medicaid long‐term care programs …”

Home‐Based Primary and Palliative Care in the Medicaid Program: Systematic Review of the Literature

“…The role of HBMC for Medicaid beneficiaries is more opaque. Medicaid has traditionally been the safety‐net healthcare program for the country and long‐term care provider for most states 5 . In 2015, it covered more than 70 million Americans with low incomes 6 .…”