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Insights on the dynamics of Medicaid.

Insights on the dynamics of Medicaid


Public policy perspective of the Medicaid program is changing. After enactment of Medicaid in 1965, public concern focused on demand for health services and patterns of growth within the program. Attention was largely placed on the extent to which the program achieved the cost, access, and quality of care objectives for the specific groups, of low-income individuals and families covered under title XIX. Today's public interest in assessing Medicaid's experiences and evolution reflects a much broader perspective on the program's potential in shaping the Nation's health care system.

Symposium participants, representing a range of outlooks and viewpoints, were asked to provide insights on how the particular structure and dynamics of the Medicaid program affect its value an effectiveness, and how the Medicaid model and the program's experiences can constructively influence health policy change. We presented the following broad questions to each contributor:

* How does the Medicaid policy and operational arena foster innovative solutions to systemic problems?

* What are the oppotunities and the value offered by State and local flexibility in tailoring the program to local needs and interests?

* What are the tradeoffs inherent in a climate of flexibility and innovation--e.g., difficulties in sharing and replicating successes or "lessons learned," in analyzing data and understanding a program characterized by variety and, hence, complexity?

* As broader health policy reform agendas evolve, what are the "lessons learned" from the Medicaid experience--e.g., in structuring balanced State-Federal control, in fostering adaptability and innovation, in meeting the needs of special populations?

* Where and how has Medicaid best "worked," taking full advantage of how it's designed? Where have the tensions inherent in the program been "healthy" ones? What hasn't worked and why?

The symposium brings together three kinds of viewpoints on these issues. James R. Tallon addresses Medicaid issues based largely on his experience as a State legislator in New York and through active participation on many committees addressing national and State health policy issues. Drew Altman's article reflects his broad managerial experience with the Medicaid program in both Federal and State government and, more recently, as Director of the Health and Human Services program at the Pew Charitable Trusts, which funds research and demonstration projects related to health care for poor and disadvantaged populations. He has recently moved to Kaiser-Permanente, where he will have an opportunity to directly influence the provision of care to Medicaid beneficiaries as President of one of the Nation's largest health maintenance organizations. Altman's coauthor is Dennis F. Beatric, who has considerable experience with the Medicaid program as a State official in New Jersey and as senior program advisor at the Pew Charitable Trusts. Gary J. Clarke analyzes Medicaid from the perspective of a State Medicaid Director who deals with the realities of administering the Florida Medicaid program on a daily basis.

Despite the different backgrounds and viewpoints of the respondents, several broad themes and issues emerge from the articles in this syposium. The first theme is the broad diversity of the structure and administration of the Medicaid program. All of the respondents note the difficulties in understanding and analyzing a program that is not designed to address the health care needs of all poor Americans on a nationally uniform basis, but rather is uniquely molded within each State to serve distinct segments of the poor population that have very different nneds. As Altman and Beatrice note: "Medicaid is really three programsd in one: a program of low-income women and children a program for the blind and disabled and a program--really a catastrophic insurance program--for the elderly in need of long-term care." This distinction raises enormous challenges for strategic policymaking, as well as program and fiscal management.

The second major theme is the transformation of State Medicaid program management beyond essential administrative processes to proactive innovation in health policy, financing, and service delivery during the past decade. All respondents note the growing inclination of State Medicaid officials to search for and develop creative solutions to pressing issues in their States. Clarke notes that many State Medicaid programs have developed considerable expertise in critical aspects of health policy and program administration in the past decade.

Another important theme is the growing tendency to associate Medicaid with potential solutions to issues with much larger social policy significance. All respondents note the increased attention given to Medicaid in addressing the problems of the medically uninsured, chemically dependent, human immunodeficiency virus infected, and functionally and cognitively disabled segments of the population as evidence of this trend. A key issue raised by all respondents is the difference strategic views of the program engendered in this debate: as a health insurance program, isolated from welfare and as a potential base for broader coverage of the medically uninsured or as a more integral part of a comprehensive set of welfare and other social service programs to address the health-related needs of low-income individuals and their families affected by the devastation of problems such as drug addiction, acquired immunodeficiency syndrome, and Alzheimer's disease. Policy choices along each of these dimensions have potentially significant implications for the future evolution of the Medicaid program.

An interesting point raised by all respondents is the importance of maintening and enhancing the basic infrastructure of health facilities and health professionals whose participation is essential for achieving program objectives. In this regard, all respondents draw special attention to the need for more initiative in the areas of primary care and obstetrics. Altman notes that " way to begin to address this problem without substantial new expenditures (is to) get serious about expanding managed care."

Finally, all respondents emphasize the difficulties confronting both the States and the Federal Government in addressing Medicaid policy issues alone. The growing demands placed on Medicaid resources in the coming years require a strengthened State-Fereal partnership to marshal program resources effectively within current Federal and State fiscal realities. Tallon's article, in particular, outlines the multiple views currently under debate for repositioning Medicaid in the search for solutions. Whether program changes are incremental or systemic, and occur slowly or rapidly, Clarke emphasizes the need to build on the States' Medicaid management expertise, their demonstrated capacity for innovation, and their ability to work directly with local agencies and providers in balancing State and Federal fiscal and policymaking responsibilities.
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Article Details
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Title Annotation:Symposium
Author:Kenesson, Mary S.; Clauser, Steven B.; Altman, Drew; Beatrice, Dennis F.; Tallon, James R., Jr.; Cla
Publication:Health Care Financing Review
Date:Jan 1, 1990
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Next Article:Trends in Medicaid payments and utilization, 1975-89.

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