The Demise of Community Responsibility: Unintended Consequences of Coverage Expansions on California Public Hospitals

Abstract

Long before the establishment of Medicaid or the passage of the Affordable Care Act, California counties provided their poorest residents with access to comprehensive medical care. This article analyzes the creation and closure of public hospitals in the state of California. It combines both qualitative historical research and event history analysis to assess what led first to the creation of the nation's most comprehensive public health network and then to its gradual demise. Strong evidence is presented that the implementation of Medicaid in California significantly altered the calculus of local governments with regard to the operation of public hospitals. In particular, Medicaid shifted county hospitals from the realm of allocational politics to that of redistributive politics. Subsequently, reforms at the state and federal levels further encouraged this development. Because of this shift, many counties decided to close their hospitals. Moreover, as expected for redistributive policies, the continued operation of public hospitals was driven not by need but instead merely by fiscal capacity: more affluent counties continue to maintain them while poorer, needier counties close their doors.

Handmaidens of the legislature? Understanding regulatory timing

“…Specifically, we rely on Royston-Parmar models, which are commonly used in the medical literature. In many respects, Royston-Parmar models (Royston 2001;Royston and Parmar 2002;Lambert and Royston 2009;Royston and Lambert 2011;Haeder 2019) provide a sound middle ground between the semiparametric Cox model and a fully parameterised approach. One advantage is Royston-Parmar models 4…”

“…While this summationwhich suggests the primacy of Congressmay be technically accurate, it also provides an incomplete picture. In particular, it ignores the fact that agencies generally control the timing of agency action, which is, in and of itself, a political decision (Carpenter 2002;Carpenter et al 2012;Callander and Krehbiel 2014;Potter 2019;Haeder andYackee 2020a, 2020b). In this article, we demonstrate that agencies routinely take years, even decades, to issue regulations in response to statutory delegations of rulemaking authority.…”

“…We employ flexible parametric models to understand the factors that speed or slow down agency responsiveness to congressional delegations of authority. These techniques, which are innovative in the field (Haeder 2019), allow us to determine the statistical and substantive significance of our theorised drivers across time, while also producing figures that jointly vary predictor variables to better understand how "real world" scenarios affect regulatory timing.…”

Political Science and U.S. Health Policy in the Era of the Affordable Care Act

“…And no doubt, the ACA serves as a tremendous test case for scholars of policy feedback, as it “trigger[ed] new paths of institutional development, generating new sets of relationships, commitments and patterns of operations […] impacting the distributional effects of health policy, the scope of decision making, and the representation of diverse interests in health policy debates” (Jacobs, , p. 625). No less, while most of the feedback studies have focused on the ACA, others have provided insights on the feedback effects of individual retirement accounts and health savings accounts (Barabas, ), the Ryan White HIV/AIDS Program (Martin & Keenan, ), immigration policing and Latino health (Cruz Nichols, LeBrón, & Pedraza, ), the closure of county hospitals (Haeder, ), and developments surrounding the Boren Amendment and Medicaid (Miller, ).…”

Policies that Bind? The use of Guidance Documents by Federal Agencies

“…This holds particularly true for health and human services policies. For instance, rules govern issues such as setting standards for Medicare Advantage plans (Haeder, 2019b(Haeder, , 2019c, establishing contraception coverage (Haeder & Yackee, 2020a), determining the adequacy of provider networks (Haeder, Weimer, & Mukamel, 2019a), and regulating nursing homes (Mukamel, Haeder, & Weimer, 2014) and hospitals (Haeder, 2019a).…”