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The Nelson A. Rockefeller Institute of Government

Health Care: Federalism


Expanding Public Health Insurance Under the Affordable Care Act:
What New York Might Learn from Connecticut, Massachusetts and Vermont

This lively, interactive public policy forum focused on how some states are expanding public health coverage in implementing the federal legislation that passed last year. The forum kicked off with presentations from speakers representing states neighboring New York. Brian Rosman of Health Care for All Massachusetts described the five-year-old Massachusetts law that is the model for federal reform law. Jill Zorn of the Universal Health Care Foundation of Connecticut discussed legislation to establish a public option — a state-run insurance plan that would compete with private insurers — when Connecticut implements federal health reform. Robin Lunge represented Vermont Governor Peter Shumlin, who is expected to sign legislation authorizing Vermont to set up a single-payer health plan, which would cover all state residents and be funded by taxpayers. New York State Senate Health Committee Chairman Kemp Hannon, Assembly Health Committee Chairman Richard Gottfried and Judy Arnold of the New York State Health Department spoke about past and current efforts aimed at expanding health coverage in New York. Also joining the forum were representatives of health insurance, hospital and insurance groups: Mary Clark of Citizen Action of New York, a consumer advocacy group; Jeffrey Gold of the Health Care Association of New York State, a group of hospitals and health care networks; and Paul Macielak of New York Health Plan Association, a trade group for managed care insurance plans.
May 19, 2011

The Adoption of Mental Health Drugs on
State AIDS Drug Assistance Program Formularies

States differ in their inclusion of drugs to treat mental illness in their programs that cover residents with HIV. Erika G. Martin, of the Rockefeller Institute and the Rockefeller College of Public Affairs & Policy, and Colleen M. Barry, of the Johns Hopkins Bloomberg School of Public Health, found three factors associated with that difference in coverage. Their findings are presented in this article.
Erika G. Martin and Colleen L. Barry, American Journal of Public Health, April 14, 2011

Q&A: What Federal Health Reform Means for the States

The effort to reform health care at the national level is a complex one. If federal legislation ultimately passes, the states will need to implement mandated changes and pay for them. The Institute's director of health policy research offers a primer of the challenges that states may face.
Courtney Burke, January 2010

Health Care Reform: What You Need to Know and
How it Will Affect New York State

Courtney Burke, who directs the Institute's Health Policy Research Center, discussed federal health reform and its effect on New York State in presentations to the State Academy of Public Administration and the Schenectady Business and Women's Association. The presentation includes a look at similarities and differences in House and Senate bills, the effective dates of various provisions and their potential impacts on the state.
Courtney Burke, January 2010

The Weakening of the States

The role of the states in American government is weakening, according to this report released at the Institute's first national conference on states' long-term budget gaps. There are three main causes: The Great Recession has strained state government finances to near the breaking point, while increasing the need for services. Medicaid continues to put heavy pressure on the finances of every state. And the information revolution has produced a de-emphasis on states generally by creating the false impression that more and more of domestic government can be micromanaged from Washington.
Richard P. Nathan, November 30, 2009

The Role of States in National Health Reform

Health insurance was the topic of the Tenth Binghamton Symposium on Health Care Management and Policy at Binghamton University's School of Management. Courtney Burke, director of the Rockefeller Institute's Health Policy Research Center, spoke about the role of the states in implementing national health reform efforts. Burke covered such topics as financing, administration, implementation and the need to address issues not covered in federal legislation, like cost and quality considerations.
Courtney Burke, October 10, 2009

Federalism by Waiver: Medicaid and the Transformation of Long-Term Care

This article focuses on 1915c program waivers, which gave states the opportunity to overcome Medicaid's institutional bias by offering more home and community-based services. The use of this tool has fueled deinstitutionalization and other program changes. It reflects the rise of executive federalism — the growing tendency for major program decisions to shift from the legislative arena to the executive branch of the national and state governments. By functioning as licenses, the 1915c waivers take devolution via the administrative process to new levels. The proliferation of these waivers suggests a need to revise prior conceptions of federal–state relations, such as picket fence federalism.
Frank J. Thompson and Courtney Burke, Publius: The Journal of Federalism, Vol. 39, No. 1,
Winter 2008

Implementing Small-Group Market Reforms: Lessons from the States

A summary of key findings from a Rockefeller Institute survey of state-level efforts to encourage and expand health insurance coverage offered by small businesses. Accompanied by these more detailed reports:

From Access to Affordability: A Summary of State Strategies to Provide Private Health Insurance to Small Businesses, 2008
The Dirigo Health Reform Act: A Case Study of Small Group Market Reform in Maine
Individual High Risk Pools: A Case Study of the Minnesota Comprehensive Health Association
Private Insurance Coverage: A Case Study of the Small Group Market in New Jersey
Maine Field Report                Minnesota Field Report                New Jersey Field Report

Devolution to the States

Over the last two decades, the issue of devolution to the states has become central to health policy debate. The critical programmatic question about devolution revolves around the degree to which federal policymakers should grant states greater discretion over goals and means. In the health care arena, there are political differences over the appropriate balance of power between the national and state governments.
Frank J. Thompson and James W. Fossett, in James A. Morone, Theodor J. Litman, and Leonard S. Robins, eds. Health Politics and Policy, Fourth Edition (Clifton Park, NY: Delmar Publishing, 2008), pp. 153-172
Order from Delmar Publishing

Executive Federalism and Medicaid Demonstration Waivers: Implications and Democratic Process

This paper examines the use of Medicaid 1115 demonstration waivers during the presidencies of William J. Clinton and George W. Bush, documenting and comparing waiver activities from the perspective of policy performance and democratic processes.
Frank Thompson and Courtney Burke, Journal of Health Policy, Politics, and Law, Vol. 32, No. 6, December 2007.

Federalism & Bioethics: States and Moral Pluralism

Bioethicists are often interested mostly in national standards and institutions, but state governments have historically overseen a wide range of bioethical issues and share responsibility with the federal government for still others. States ought to have an important role. By allowing for multiple outcomes, the American federal system allows a better fit between public opinion and public policies.
James Fossett, Alicia R. Ouellette, Sean Philpott, David Magnus, and Glenn McGee, Hastings Center Report, November-December 2007

‘Federal’ Health Care Reform Will Rely On the States

Health care is one of the most talked-about issues in the 2008 presidential campaign. And for all the differences among the leading candidates, there are also important similarities. Among these, one stands out: the central role the 50 states will play in health care reform, regardless of who wins the White House. Courtney Burke, November 2007

Federalism by Necessity: State and Private Support for Human Embryonic Stem Cell Research

States and private foundations are spending substantial amounts on human embryonic stem cell research and are likely to continue to do so, according to James W. Fossett of the Rockefeller Institute's Federalism and Bioethics Initiative. In response to a political gridlock in Washington over federal funding for this research, states and private foundations have devoted unusually large amounts of money to support this research in a number of ways. It seems likely that this situation will continue even past the elections of 2008, no matter who wins.
James W. Fossett, August 9, 2007

Federalism and Health Policy

Many social policy initiatives are tested and refined at the state level, especially during conservative periods, and later morph into national policies. The paper describes such federalism cycles and offers an interpretation of why and how they occur, focusing on Medicaid.
Richard Nathan, Health Affairs, November/December 2005.

Administrative Responsiveness to the Disadvantaged: The Case of Children's Health Insurance

This study focuses on two means-tested programs in the context of American federalism, Medicaid, and the State Children's Health Insurance Program.
James Fossett and Frank J. Thompson, Journal of Public Administration Research and Theory, September 2005

State-Local Relations and Their Effect on Policy Design and Implementation

The purpose of this brief is to report findings from an 18-state comparative study that shed light on state-local relations and their possible effects on Medicaid and CHIP enrollments of children and adults and Medicaid "take-up" rates.
Malcolm L. Goggin, May 2003

A New Puzzle for Federalism: Different State Responses to Medicaid and Food Stamps

Devolution has given states greater decision-making authority in both health care policies and the Food Stamp Program in recent years. This paper looks at various experiences in these program areas that raise important questions about the adequacy of the dominant theoretical traditions of federalism.
James W. Fossett and Thomas L. Gais, presented at the American Political Science Association Annual Meeting, August 2002