Policy Analysis

How States Stand to Gain or Lose Federal Funds by Opting In or Out of the Medicaid Expansion

How States Stand to Gain or Lose Federal Funds by Opting In or Out of the Medicaid Expansion
The Commonwealth Fund Vol 32, December 2013

Sherry Glied and Stephanie Ma
12/05/2013

Following the Supreme Court's decision in 2012, state officials are now deciding whether to expand their Medicaid programs under the Affordable Care Act. While the states' costs of participating in the Medicaid expansion have been at the forefront of this discussion, the expansion has much larger implications for the flow of federal funds going to the states. This issue brief examines how participating in the Medicaid expansion will affect the movement of federal funds to each state. States that choose to participate in the expansion will experience a more positive net flow of federal funds than will states that choose not to participate. In addition to providing valuable health insurance benefits to low-income state residents, and steady sources of financing to state health care providers, the Medicaid expansion will be an important source of new federal funds for states.

Hospitalization for Ambulatory-care sensitive conditions (ACSC) in Ile de France: A view from across the Atlantic

Hospitalization for Ambulatory-care sensitive conditions (ACSC) in Ile de France: A view from across the Atlantic
Revue française des affaires sociales 2013/3 (n° 3)

Rodwin, V., Gusmano, M. and Weisz, D.
12/03/2013

This article presents an indicator used in the United States and other OECD nations (hospitalizations for ambulatory-care sensitive conditions – ACSC) to assess access to primary care services and their capacity to handle a set of medical conditions before they require acute hospital treatment. Based on a study of Ile de France, which relies on residence-based hospital discharge data on patient diagnoses and treatments, the indicator identifies areas where hospitalizations for ACSC appear particularly high. Such hospital stays are considered potentially avoidable. Based on data from the Programme de m.dicalisation des syst.mes d’information (PMSI), disparities are measured. We rely on logistic regression analysis to identify a range of individual factors and neighborhood-level factors that explain these disparities. Access to primary care appears to be worse among residents in areas with average household income in the lowest quartile and among those hospitalized in public hospitals. This raises an important question for the future of health policy. Should areas with higher hospital discharge rates of ACSC be understood as having populations with poor health-seeking behaviors or health care systems not well enough organized to target higher-risk populations?

The Price of Liquor is Too Damn High: State Facilitated Collusion and the Implications for Taxes

The Price of Liquor is Too Damn High: State Facilitated Collusion and the Implications for Taxes

Rao, Nirupama S. (with Chris Conlon)
12/02/2013

Alcohol markets are subject to both heavy regulation as well as excise taxes at the federal and state level. We examine the impact of particular state regulations on the structure of the alcohol market. We show that post and hold and meet but not beat pricing regulations at the wholesale level eliminate competitive incentives among whole-sellers and minimum retail markup rules at the retailer level e ectively allow whole-sellers to set retail price floors. Our model suggests that without any competitive incentives at the wholesale level, firms will set prices as if they were a single monopolist. Wholesalers will tend to mark up premium brands relative to call or well products. Regression results indicate that states featuring post and hold regulations consume 4% to 10% less alcohol than other states, suggesting that the regulations may over-restrict quantity. Tabulations suggest that premium products comprise a smaller share of consumption in post and hold states. This output gap due to collusive pricing leads any taxes levied on the liquor market to entail greater deadweight loss relative to a competitive wholesale market. We conduct an empirical analysis, where instead of providing wholesalers with market power, the state increases taxes to keep the overall level of alcohol consumption fixed. We also compute the deadweight loss of increasing taxation under both the existing scheme, and one with a competitive wholesale market. We find that the state of Connecticut could substantially increase taxes and tax revenues without affecting aggregate quantities if it repealed post and hold. Back of the envelope estimates suggest that Connecticut is forgoing over $300M in potential revenue from alcohol taxes in a competitive wholesale market.

Public Policy Investment: Policy Prioritization and British Statecraft

Public Policy Investment: Policy Prioritization and British Statecraft
Oxford University Press 2013. ISBN 978-0-19-966397-2.

Anthony Bertelli and Peter C. John
11/28/2013

This book addresses one of the enduring questions of democratic government: why do governments choose some public policies but not others? Political executives focus on a range of policy issues, such as the economy, social policy, and foreign policy, but they shift their priorities over time. Despite an extensive literature, it has proven surprisingly hard to explain policy prioritisation. To remedy this gap, this book offers a new approach called public policy investment: governments enhance their chances of getting re-elected by managing a portfolio of public policies and paying attention to the risks involved. In this way, government is like an investor making choices about risk to yield returns on its investments of political capital. The public provides signals about expected political capital returns for government policies, or policy assets, that can be captured through expressed opinion in public polls. Governments can anticipate these signals in the choices they make. Statecraft is the ability political leaders have to consider risk and return in their policy portfolios and do so amidst uncertainty in the public's policy valuation. Such actions represent the public's views conditionally because not every opinion change is a price signal. It then outlines a quantitative method for measuring risk and return, applying it to the case of Britain between 1971 and 2000 and offers case studies illustrating statecraft by prime ministers, such as Edward Heath or Margaret Thatcher. The book challenges comparative scholars to apply public policy investment to countries that have separation of powers, multiparty government, and decentralization.

Pension Obligation Bonds and Government Spending

Pension Obligation Bonds and Government Spending
Public Budgeting and Finance, 33(4):43-65

Thad Calabrese and Todd Ely
10/29/2013

We examine the use of pension obligation bonds (POBs) as a financing strategy to address the effects of unfunded pension liabilities on government operating budgets. POBs are publicly marketed as money-saving mechanisms that reduce pension system payments while allowing for increased spending on other government priorities. We review general POB usage and examine whether POBs altered school district spending patterns in Oregon and Indiana. Our results indicate that districts issuing POBs have not increased educational spending relative to other districts. Because POBs cost money to issue and manage, decision makers are encouraged to consider annual budgetary effects prior to issuance.

Calorie Labeling, Fast Food Purchasing and Restaurant Visits

Calorie Labeling, Fast Food Purchasing and Restaurant Visits
Obesity, 21: 2172–2179. doi: 10.1002/oby.20550

Elbel, B., Mijanovich, T., Dixon, L. B., Abrams, C., Weitzman, B., Kersh, R., Auchincloss, A. H. and Ogedegbe, G.
10/17/2013

Objective
Obesity is a pressing public health problem without proven population-wide solutions. Researchers sought to determine whether a city-mandated policy requiring calorie labeling at fast food restaurants was associated with consumer awareness of labels, calories purchased and fast food restaurant visits.

Design and Methods
Difference-in-differences design, with data collected from consumers outside fast food restaurants and via a random digit dial telephone survey, before (December 2009) and after (June 2010) labeling in Philadelphia (which implemented mandatory labeling) and Baltimore (matched comparison city). Measures included: self-reported use of calorie information, calories purchased determined via fast food receipts, and self-reported weekly fast-food visits.

Results
The consumer sample was predominantly Black (71%), and high school educated (62%). Postlabeling, 38% of Philadelphia consumers noticed the calorie labels for a 33% point (P < 0.001) increase relative to Baltimore. Calories purchased and number of fast food visits did not change in either city over time.

Conclusions
While some consumers report noticing and using calorie information, no population level changes were noted in calories purchased or fast food visits. Other controlled studies are needed to examine the longer term impact of labeling as it becomes national law.

Public Policy Investment: Risk and Return in British Politics

Public Policy Investment: Risk and Return in British Politics
British Journal of Political Science, 43, pp 741-773. doi:10.1017/S0007123412000567.

Anthony M. Bertelli and Peter John
10/01/2013

This article sets out and tests a theory of public policy investment – how democratic governments seek to enhance their chances of re-election by managing a portfolio of policy priorities for the public, analogous to the relationship between investment manager and client. Governments choose policies that yield returns the public values; and rebalance their policy priorities later to adjust risk and stabilize return. Do the public reward returns to policy capital or punish risky policy investments? The article investigates whether returns to policy investment guide political management and statecraft. Time-series analyses of risk and return in Britain 1971–2000 reveal that risk and return on government policy portfolios predict election outcomes, and that returns, risk profiles and the uncertainty in public signals influence the prioritization of policies.

Democratization and Universal Health Coverage: A comparison of the experiences of Ghana, Kenya, and Senegal

Democratization and Universal Health Coverage: A comparison of the experiences of Ghana, Kenya, and Senegal
Global Health Governance, 6(2): 1-27.

Grépin, Karen and Kim Yi Dionne
09/23/2013

This article identifies conditions under which newly established democracies adopt Universal Health Coverage. Drawing on the literature examining democracy and health, we argue that more democratic regimes – where citizens have positive opinions on democracy and where competitive, free and fair elections put pressure on incumbents – will choose health policies targeting a broader proportion of the population. We compare Ghana to Kenya and Senegal, two other countries which have also undergone democratization, but where there have been important differences in the extent to which these democratic changes have been perceived by regular citizens and have translated into electoral competition. We find that Ghana has adopted the most ambitious health reform strategy by designing and implementing the National Health Insurance Scheme (NHIS). We also find that Ghana experienced greater improvements in skilled attendance at birth, childhood immunizations, and improvements in the proportion of children with diarrhea treated by oral rehydration therapy than the other countries since this policy was adopted. These changes also appear to be associated with important changes in health outcomes: both infant and under-five mortality rates declined rapidly since the introduction of the NHIS in Ghana. These improvements in health and health service delivery have also been observed by citizens with a greater proportion of Ghanaians reporting satisfaction with government handling of health service delivery relative to either Kenya or Senegal. We argue that the democratization process can promote the adoption of particular health policies and that this is an important mechanism through which democracy can improve health.

Scientific Publications on Firearms in Youth Before and After Congressional Action Prohibiting Federal Research Funding

Scientific Publications on Firearms in Youth Before and After Congressional Action Prohibiting Federal Research Funding
Journal of the American Medical Association [JAMA];310(5): 532-533.

Ladapo, Joseph, Benjamin Rodwin, Andrew M. Ryan, Leonardo Trasande, Jan Blustein
09/04/2013

In January 1996, Congress passed an appropriations bill amendment prohibiting the US Centers for Disease Control and Prevention (CDC) from using “funds made available for injury prevention … to advocate or promote gun control.” This provision was triggered by evidence linking gun ownership to health harms, created uncertainty among CDC officials and researchers about what could be studied, and led to significant declines in funding. We evaluated the change in the number of publications on firearms in youth compared with research on other leading causes of death before and after the Congressional action. We focused on children and adolescents because they disproportionately experience gun violence and injury.

Medicaid's Next Metamorphosis

Medicaid's Next Metamorphosis
Public Administration Review, Vol 73, no. 4

Charles Brecher and Shanna Rose
08/20/2013

Medicaid’s transformation since its inception rivals the biological changes of metamorphosis, and that process is not yet over. Past metamorphoses are the change from a small program with eligibility linked to the states’ cash welfare benefits to one with national eligibility standards covering many not receiving cash benefits, from a traditional fee-for-service payment program to one dominated by capitated managed care arrangements, and under the ACA to a widely accepted component of a national system for near universal insurance coverage. An analysis of the forces behind these significant changes suggests that future transformations are likely, and four potential scenarios are presented and assessed.

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