Opting to opt-in: policy choice, program expectations and results in West Virginia's Medicaid reform initiative.

Following the passage of the Federal Deficit Reduction Act in 2005, a few states, including West Virginia, redesigned their Medicaid programs to emphasize personal responsibility and consumer-driven health decisions. The West Virginia program was implemented in 2006 and was subsequently abandoned in 2010 due to changes in Federal laws and continuing criticism by advocacy groups whose expectations for enrollment in a wellness-based plan were not met. Using the results of a survey of the West Virginia members, the authors explore the public policy and implementation factors of this program. We argue that initial policy design relied on existing implementation mechanisms, while it needed specific tactics to address the novelty of the choice members were facing. With the passage of the Patient Protection and Affordable Care Act, the West Virginia results provide valuable insights for future health reform policy implementation, especially as they relate to consumer-directed health decision-making and the role of intermediaries who can play a role in assisting consumers in their choices.

AN UNCERTAIN FEDERALISM: THE STATES AND THE AFFORDABLE CARE ACT.

This article provides an initial assessment of the Affordable Care Act's recent implementation experience in the states. Drawing on state-level and regional analyses that have been coordinated by the ACA Implementation Network--a cooperative effort involving researchers in 35 states--this article highlights the uncertain policy environment associated with the politics and complexities of the ACA. Understanding the ACA implementation experience requires an appreciation for political context, but must also take into account underlying demographic, market, and state administrative capacity issues in the states. There are indications that the ACA implementation experience is moving from a highly charged partisan nature to a more accommodating posture long associated with intergovernmental relations between the federal and state government in health and human services administration. In short, the key questions going forward will turn on how, not whether, the ACA is implemented.

Federalism, intergovernmental relations, and the challenge of the medically uninsurable: a retrospective on high risk pools in the states.

While relatively overlooked in health policy research and analysis, state high risk insurance pools play a notable role in contemporary health policy arrangements. Also know as State Comprehensive Health Insurance Plans, high-risk pools emerged in the late 1970s as states began to grapple with the challenges of the medically uninsured. Today, thirty-five states operate these programs. To further our understanding of health and human services administration, it is important to examine these plans, especially in context of intergovernmental health policy in the United States. This analysis provides an overview of high risk pool evolution and gives attention to forces that have shaped their development, such as model legislation, funding arrangements, and increasing federal-level interest in their use as platforms to advance national policy initiatives.

Activism in an age of restraint: the resiliency of administrative structure in implementing the State Children's Health Insurance Program.

This article examines state efforts to build administrative structures and outreach networks in the State Children's Health Insurance Program (CHIP) through a comparative review of 18 states that have been the subject of ongoing research by the Nelson A. Rockefeller Institute of Government. The article explores the role that institutional structures play at the state level in shaping the implementation and administration of federal policy choices. States have generally opted to rely largely on existing Medicaid bureaucracies in order to implement the new CHIP programs. As a result, CHIP programs have been tightly integrated into existing Medicaid structures. Rarely put forward as exemplars of responsiveness and, these bureaucracies have nonetheless played a crucial role in building and managing CHIP programs across the United States. As this analysis will show, this has even been the case in those few states that have opted to officially house CHIP administration outside of the Medicaid bureaucracy. Furthermore, existing Medicaid systems have often been active as partners and participants in efforts to publicize and promote the CHIP program through outreach and education efforts. As part of these initiatives, efforts have been made to portray CHIP as a form of health insurance rather than a welfare benefit. A slight paradox results where key actors in the health and human services bureaucracy play an active role in program management while making efforts to dissassociate the program from the traditional welfare system. These efforts have been largely successful. And in doing so, not only have children been brought into the CHIP program but more families have been connected to the Medicaid program. In short, a review of state experiences reveals the resiliency and flexibility of existing state administrative systems in responding to and addressing substantive policy change.