Where You Live Matters: Quality and Racial/Ethnic Disparities in Schizophrenia Care in Four State Medicaid Programs.

OBJECTIVE: To determine whether (a) quality in schizophrenia care varies by race/ethnicity and over time and (b) these patterns differ across counties within states. DATA SOURCES: Medicaid claims data from California, Florida, New York, and North Carolina during 2002-2008. STUDY DESIGN: We studied black, Latino, and white Medicaid beneficiaries with schizophrenia. Hierarchical regression models, by state, quantified person and county effects of race/ethnicity and year on a composite quality measure, adjusting for person-level characteristics. PRINCIPAL FINDINGS: Overall, our cohort included 164,014 person-years (41-61 percent non-whites), corresponding to 98,400 beneficiaries. Relative to whites, quality was lower for blacks in every state and also lower for Latinos except in North Carolina. Temporal improvements were observed in California and North Carolina only. Within each state, counties differed in quality and disparities. Between-county variation in the black disparity was larger than between-county variation in the Latino disparity in California, and smaller in North Carolina; Latino disparities did not vary by county in Florida. In every state, counties differed in annual changes in quality; by 2008, no county had narrowed the initial disparities. CONCLUSIONS: For Medicaid beneficiaries living in the same state, quality and disparities in schizophrenia care are influenced by county of residence for reasons beyond patients' characteristics.

Explaining variations in state foster care maintenance rates and the implications for implementing new evidence-based programs.

BACKGROUND: U.S. Child Welfare systems are involved in the lives of millions of children, and total spending exceeds $26 billion annually. Out-of-home foster care is a critical and expensive Child Welfare service, a major component of which is the maintenance rate paid to support housing and caring for a foster child. Maintenance rates vary widely across states and over time, but reasons for this variation are not well understood. As evidence-based programs are disseminated to state Child Welfare systems, it is important to understand what may be the important drivers in the uptake of these practices including state spending on core system areas. DATA AND METHODS: We assembled a unique, longitudinal, state-level panel dataset (1990-2008) for all 50 states with annual data on foster care maintenance rates and measures of child population in need, poverty, employment, urbanicity, proportion minority, political party control of the state legislature and governorship, federal funding, and lawsuits involving state foster care systems. All monetary values were expressed in per-capita terms and inflation adjusted to 2008 dollars. We used longitudinal panel regressions with robust standard errors and state and year fixed effects to estimate the relationship between state foster care maintenance rates and the other factors in our dataset, lagging all factors by one year to mitigate the possibility that maintenance rates influenced their predictors. Exploratory analyses related maintenance rates to Child Welfare outcomes. FINDINGS: State foster care maintenance rates have increased in nominal terms, but in many states, have not kept pace with inflation, leading to lower real rates in 2008 compared to those in 1991 for 54% of states for 2 year-olds, 58% for 9 year-olds, and 65% for 16 year-olds. In multivariate analyses including socioeconomic, demographic, and political factors, monthly foster care maintenance rates declined $15 for each 1% increase in state unemployment and declined $40 if a state's governorship and legislature became Republican, though significance was marginal. In analyses also examining state revenue, federal funding, and legal challenges, maintenance rates increased as the federal share of maximum TANF payments increased. However, >50% of variation in foster care maintenance rates was explained by unobserved state-level factors as measured by state fixed effects. These factors did not appear to be strongly related to 2008 Child Welfare outcomes like foster care placement stability and maltreatment which were also not correlated with foster care maintenance rates. CONCLUSIONS: Despite being part of a social safety net, foster care maintenance rates have declined in real terms since 1991 in many states, and there is no strong evidence that they increase in response to harsher economic climates or to federal programs or legal reviews. State variation in maintenance rates was not related to Child Welfare outcomes, though further analysis of this important relationship is needed. Variability in state foster care maintenance rates appears highly idiosyncratic, an important contextual factor to consider when designing and disseminating evidence-based services.

There is little experience and limited data to support policy making on integrated care for dual eligibles.

Coordinating care for the nine million elderly or disabled and low-income people who are dually eligible for Medicare and Medicaid is a pressing policy issue. To support the debate over this issue, we synthesized public data on how services are provided to dual eligibles receiving covered benefits in both programs. Our analysis confirmed that most dual-eligible beneficiaries receive benefits separately for each program through fee-for-service arrangements. Their enrollment in Medicare and Medicaid managed care is growing but still low, with highly uneven experiences across states. Few states or health plans have experience with coordinating care for dual eligibles within an integrated plan. These findings reinforce the need for caution in considering policies that would rapidly give states the responsibility for coordinating dual eligibles' care and coverage. We also found data gaps that warrant prompt attention in order to provide national-level oversight and improve the evidence base for debating and tracking policy changes.

Medicaid expansion under health reform may increase service use and improve access for low-income adults with diabetes.

Medicaid's key role in financing diabetes care will grow when many low-income uninsured people with diabetes gain eligibility to the program in 2014 under the Affordable Care Act. Using a national data set to describe current health care use and spending among the nonelderly, low-income adult population, we found that adult Medicaid beneficiaries with diabetes had total annual per capita health expenditures more than three times higher ($14,229 versus $4,568) than those of adult beneficiaries without diabetes. At the same time, Medicaid facilitates financial protection and care access among beneficiaries with diabetes. Low-income adults with diabetes who were uninsured used fewer services, spent more out of pocket, and reported worse access than did their peers who were covered by Medicaid. Uninsured adults with diabetes who gain Medicaid coverage under health reform are likely to enter the program with unmet needs, and coverage is likely to result in both improved access and increased use of health care.

Behavioral health services in separate CHIP programs on the eve of parity.

The Children's Health Insurance Program (CHIP) plays a vital role in financing behavioral health services for low-income children. This study examines behavioral health benefit design and management in separate CHIP programs on the eve of federal requirements for behavioral health parity. Even before parity implementation, many state CHIP programs did not impose service limits or cost sharing for behavioral health benefits. However, a substantial share of states imposed limits or cost sharing that might hinder access to care. The majority of states use managed care to administer behavioral health benefits. It is important to monitor how states adapt their programs to comply with parity.

The impact of national health care reform on adults with severe mental disorders.

OBJECTIVE: Little is known about the effect recent health care reform legislation will have on coverage of individuals with severe mental disorders. The authors examined current and predicted sources of insurance coverage and use of mental health services among adults with and without severe mental disorders and modeled postreform changes. METHOD: The authors obtained sociodemographic, health status, mental health care use, and insurance coverage data from the 2004-2006 Medical Expenditure Panel Surveys to estimate changes that will occur after reform is fully implemented in 2019. RESULTS: Adults with severe mental disorders, identified as self-reported severe depression or other psychological distress, were more likely than those without such disorders to be uninsured (21.0% compared with 16.5%). Only one-fifth of individuals with severe mental disorders who lacked full-year insurance coverage had any mental health service use in the 2004-2006 period, compared with approximately half of those who had coverage. The authors estimate that the expansion of insurance coverage under reform will lead to 1.15 million new users of mental health services, which represents a 4.5% increase. The authors estimate an increase of 2.3 million users of mental health services in Medicaid and nearly 2 million in private insurance. CONCLUSIONS: Public insurance programs that currently play a major role in financing mental health services will play an even greater role after reform is implemented. Significant increases can be expected both in the overall number of users of mental health services and in their resources to pay for care.

Health reform and the scope of benefits for mental health and substance use disorder services.

The Patient Protection and Affordable Care Act will expand insurance coverage to millions of Americans with mental disorders. One particularly important implementation issue is the scope of mental health and substance abuse services under expanded health insurance coverage. This article examines current public and commercial insurance coverage of the range of services used by individuals with mental illnesses and substance use disorders and assesses the implications of newly mandated standards for benefit packages offered by public and private plans. The authors note that many services needed by individuals with mental or substance use disorders fall outside the scope of benefits currently covered by a typical private insurance plan. Compared with other insurers, Medicaid currently covers a broader range of behavioral health services; however, individuals moving into Medicaid under new eligibility pathways will receive "benchmark" or "benchmark-equivalent" coverage rather than full Medicaid benefits. If behavioral health benefits are set at those currently available in typical private plans or in benchmark coverage, some newly insured individuals with mental illnesses or substance use disorders who are covered by private plans or Medicaid expansions are still likely to face gaps in covered services. Policy makers have several options for addressing these likely gaps in coverage, including requiring states to maintain coverage of some support services, including certain behavioral health services in the "essential benefits package," and expanding eligibility for full Medicaid benefits.

Mental health policy development in the States: the piecemeal nature of transformational change.

OBJECTIVE: Transformation--systemic, sweeping changes to promote recovery and consumerism--is a pervasive theme in discussions of U.S. mental health policy. State systems are a fundamental component of national transformation plans. However, it is not clear how the vision of transformation will be balanced against the idiosyncratic political forces that traditionally characterize state policy making. This article examines the development of state mental health policy to assess whether and how it reflects the broader context of transformation versus political forces. METHODS: Analysis used qualitative evidence collected from semistructured interviews in four states (California, Massachusetts, New Jersey, and New Mexico), which were chosen to capture variation in geography and population, health systems, and political environment. Interviewees included 35 key mental health officials, directors of principal mental health consumer and family advocacy groups, and executives of major mental health provider groups. Interviews were conducted between May 2007 and March 2008. RESULTS: Many recent state policy priorities in mental health are consistent with the overall goals of transformation, but some are particular to a state's circumstance. The case studies showed that these priorities are largely shaped by executive control, stakeholder interests, and crises. There is mixed evidence on whether these drivers of state priorities reflect an underlying transformative process. CONCLUSIONS: States' mental health policies are largely guided by the problems and resources of the states: sometimes these forces dovetail with nationwide transformation goals and processes, and sometimes they are idiosyncratic to a particular state. Thus, although states can play an integral role in forwarding transformation, their own mental health policy agendas are not eclipsed by this nationwide movement.

Managed behavioral health care carve-outs: past performance and future prospects.

As the managed behavioral health care market has matured, behavioral health carve-outs have solved many problems facing the delivery of behavioral health services; at the same time, they have exacerbated existing difficulties or created new problems. Carve-outs developed to address rising inpatient behavioral health costs and limited insurance coverage. They are based on the economic principles of economies of specialization, economies of scale, price negotiation, and selection. Literature shows that carve-outs have been successful in lowering costs and maintaining or improving access, but results on their impact on quality of care are mixed. In recent years, carve-outs have evolved to take on new roles within the health system, such as coordinating mental and physical health, addressing fragmented public financing systems, and using market power to implement quality improvement. Although not perfect, carve-outs have been instrumental in addressing long-standing challenges in utilization, access, and cost of behavioral health care.

State preparedness for bioterrorism and public health emergencies.

The nation's ability to prepare for and respond to an infectious disease or bioterrorist attack rests largely in states' public health systems. Early federal efforts to provide funding to help states and localities build their infrastructure have led to a great deal of activity in this area. Evaluations of progress in preparedness show both successes and shortcomings, and assessments of whether or not the nation is prepared vary depending on benchmarks used and perspectives on spending priorities. Future assessments will be needed for continuous monitoring of improvements and challenges.

Accomplishments and challenges in Medicaid mental health.

Although Medicaid was not designed as a mental health program, it is now a major source of financing for mental health services and care, especially for the chronically mentally ill. This paper examines the role Medicaid plays today for the low-income population with mental health needs and then reviews some of the current pressures and challenges in the program that could reshape this role.

Historical overview of children's health care coverage.

America's public health insurance programs reflect a deeply rooted commitment to caring for low-income families and children. This article chronicles the evolution of Medicaid and the State Children's Health Insurance Program (SCHIP), two public programs designed to provide free or low-cost health coverage to low-income children who do not have access to private health insurance. Such a historical overview is key to understanding where the programs come from and the challenges that policymakers must grapple with in order to effectively provide health coverage to children. Depression-era maternal and child health programs created the foundation for Medicaid. Expansions of the program during the 1980s and 1990s made Medicaid the largest single insurance provider for children in the United States. In 1997, SCHIP boosted these efforts by filling the gap between Medicaid and employment-based coverage. In addition to expanding coverage, SCHIP also motivated efforts to address obstacles to coverage such as application and enrollment procedures. Together, SCHIP and Medicaid have made significant progress in providing health coverage to children in low-income families. They are the primary sources of coverage for children in low-income families. In a discussion of major challenges to providing public health coverage to children, the authors highlight some important issues that threaten current progress, such as rising health care costs and falling state revenues, gaps in coverage, and remaining barriers to enrollment and retention.

Health insurance for unemployed workers.

OBJECTIVE: In this article, we seek to inform the debate over providing assistance to workers who lose their jobs during the recession by assessing the potential impact of an economic downturn on health insurance coverage and reviewing available approaches to secure coverage for unemployed workers and their families. We also summarize recent research and analysis to examine the likely challenges and benefits of these approaches. DATA SOURCE: Data and analysis are primarily based on the Census Bureau's Current Population Survey, the Urban Institute's National Survey of America's Families, and Medicaid data from the Centers for Medicare and Medicaid Services. We also draw on recent surveys and analysis conducted by researchers in the health policy field. CONCLUSIONS: Maintaining health insurance coverage for unemployed workers is important to helping individuals and to stimulating our economy. While some families may be assisted by efforts to subsidize COBRA extension coverage, the potential reach of such an initiative is limited. Building on public programs such as Medicaid offers a targeted, efficient, and effective option but also presents financing challenges to federal and state governments.

Health Care for the Poor: Medicaid at 35.

Over its 35-year history, Medicaid has grown from a program to provide health insurance to the welfare population to one that provides health and long-term care (LTC) services to 40 million low-income families and elderly and disabled individuals. Despite its accomplishments in improving access to health care for low-income populations, Medicaid continues to face many challenges. The future of Medicaid as our Nation's health care safety net will be determined by Medicaid's ability to broaden health coverage for the low-income uninsured, secure access to quality care for its growing beneficiary population, and manage costs between the Federal and State governments.