Medicaid is the federal government's largest single welfare program for the poor. Its costs now exceed the costs of all other public assistance programs- including family assistance, SSI, and the food stamp program. Medicaid was established in 1965 and grew quickly into the nation's largest welfare program. Since then, there have been many policy changes in the program implemented by the government, like the introduction of the Affordable Care Act, because of the issues rising in the series of its implementation and based on the evaluations done by research organizations of government, private institutions, and interest groups. The way government implements and administers such programs for the welfare of the public can be best illustrated with the process of Policy making, their evaluation, and the issues arising out of their implementation.
Public policy is said to be what the governments wish to do or not to do. Governments implement several laws which may or may not be accepted by the people. It provides many services, facilities, and entitlements, in lieu of some taxes. Thus, the policies implemented may regulate the way people behave, provide services, and collect taxes.
Thomas R. Dye has cited other definitions of Public Policy by several political scientists and philosophers:
"David Easton, a political scientist, defines public policy as 'the authoritative allocation of values for the whole society;' Harold Lasswell, a political scientist and Abraham Kaplan, a philosopher, define public policy as a 'a projected program of goals, values, and practices,' and political scientist Carl Friedrick says, 'It is essential for the policy concept that there be a goal, objective, or purpose'" (Dye, 2008).
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There are other ways of defining public policy by breaking down this general notion into various component parts. This was brought about by a political scientist Charles O. Jones, proposed the distinction among various proposals (specified means for achieving goals), programs (authorized means for achieving goals), decisions (specific actions taken to implement programs), and effects (the measurable impacts of programs) be considered. (Dye, 2008)
Models of Politics
A model can be a way of illustrating some aspect of the real world. In politics, political scientists use a flow chart to show how a law is derived from a bill.
The models used or employed for studying policy are conceptual models which make it easy and clear to know about politics and public policy, recognize the important aspects of policy problems, derive explanations for public policy and predict its consequences. (Dye, 2008)
The different policy models used to examine public policy are:
Public choice model
Game theory model
Here the Policy is reviewed, using the Incremental model of politics. The Incremental model is a conservative model, in which, considering the existing programs, policies, and expenditures as a base, attention is concentrated on new programs and on increases, decreases, or modifications of existing programs. The process can be exemplified with budgetary policy for any government activity or programs for a given year. This process is preferred for many reasons, first being, economic hardships, absence of details on demand survey, authenticity or inappropriate statistical feed-back from the relevant fields and time required to investigate all the alternatives in the existing policy. The others are, legitimacy of the existing policies is accepted by policy makers, since they do not want to try any new programs due to lack of enthusiasm and creativity in the bureaucracy, fearing the uncertain consequences of the new policies. Then, the existing policies, which are deep-rooted enough, because of heavy investments, make it difficult for the policy makers to take any radical decision. Lastly, policies like these are accepted easily compared to new policies. Thus, incrementalism is important in maintaining stability and preserving the political system in almost status-quo with sight variations.
The issues being addressed here may not be totally termed as correlated with this incrementalism model, since they are budgetary policies being addressed by the New York state government, with utmost care and dedication with profound application of sincerity. Thus, the programs Medicaid and Affordable Care Act, which have been successful mostly in serving most of the needy, had a few challenges which aptly require only few changes. Contrary to the rational changes, which require a lot additional resources, the solutions provided appear to be easier and less expensive to implement, like the ones suggested by the Medicaid Redesign Team, for the New York State Budget for the year 2011-2012.
The Policymaking Process
The process of policy making is a process of how policies are made, in a step-by step sequence, but these processes never occur in a sequence in reality.
Problem identification: Though the society may sustain many issues, only a few are considered to become a policy, to become an agenda for the government. This is influenced by the interest groups, pressure groups, media who communicate the issues to the government. Thus influencing the decision making process. If such groups do not come up with any objections on a certain policy implemented by the government, it is considered that the policy has been accepted by most people. Thus the mass media, interest groups, citizen initiatives, public opinion become the major participants of this step (Dye, 2008).
Agenda Setting: The process by which ideas or issues are brought up by the various political channels to be considered by a political institution such as legislature or court. Moreover, the administrative agencies of a government often generate and formulate proposals, which may be incorporated into the executive's legislative recommendations for a careful consideration by the legislative body (Shafritz, E. W. Russell, & Borick, 2008).
Non decision making: Though there may be many public issues arising, politicians try to suppress them from becoming policy issues. Non decision making occurs when some powerful elite groups which always keep an eye on Government policies, implementation programs and reactions of the people, act openly or covertly to suppress an issue because of the fear that if attention is focused on certain policy issues, something will be done and it may not be in their interest (Dye, 2008).
Formulating policy: It is way of drafting a document on policy alternatives for dealing with issues in the interest of public welfare and development on public agenda. It takes place in the government bureaucracies; offices agencies of interest group/pressure- groups; legislative committee rooms; meetings of special commissions appointed by the Government; and policy planning organizations otherwise known as think tanks. These are considered to be the central coordinating points in the policy making process. Some of them are the Council on the Foreign Relations, the American Enterprise Institute, Heritage Foundation, and the Brookings Institution. They can influence a wide range of important policy areas. Other policy planning groups-the Urban Institute, Resources for the Future, the Population Council, for example -concentrate on a particular policy area.
Interest groups: The interest groups influence the government policy in a variety of ways like Direct lobbying, Contributions made through Political Action Committees (PACs), Interpersonal contacts, between government offices and the industries and organizations representing them, Litigation designed to force changes in policies through the court system, and grassroots mobilization efforts to influence Congress and the White House by encouragement from individual constituents and campaign contributors (Dye, 2008).
Policy Legitimation: The process by which a public policy is enacted into a law, after verification by all the legal institutions. The people involved with this process are called proximate policy makers, who include the president, congress, courts, federal agencies, congressional committees, White house staff, and interest groups. They are the ones responsible for bringing a public policy into action, by putting up a bill in the congress, or by any other way.
Policy Implementation: It includes all of the activities designed to carry out the policies enacted by the legislative branch. These activities include the creation of new organizations- departments, agencies, bureaus, and so on -or the assignment of new responsibilities to existing organizations. They must translate laws into operational rules and regulations. They employ and deploy personnel, draw up contracts, sanction required funds and perform tasks. The bureaucrats or executional bodies of public administration in Government play a major role in this process, since the political leaders give only broad instructional outlines in the legislature meetings to the Government to define these policies and set rules at the basic level (Dye, 2008).
Policy Evaluation: It is the process which helps the Congress, the President, interest groups, bureaucrats, the media, think tanks know whether or not the policies implemented by them are achieving their stated goals; at what costs; and with what effects, intended and unintended, on society. Thus evaluations of current policy may recognize new problems and restart the policymaking process. It may be mostly impressionistic rather than systematic, where impressionistic would indicate the complaints and the media stories about the laws passed and implemented, and systematic evaluation indicates what is done by the government in a systematic, careful, objective, scientific assessment of the current and long-term effects of policies on both target and non-target subjects or groups, and the costs and benefits involved (Dye, 2008).
Medicaid is the United States health program for people and families with low incomes and resources. It is a program that is jointly funded by the state and federal governments, and is managed by the states (Overview-Medicaid Program - General Information).
Being the federal government's largest single welfare program for the low income group as a pure welfare measure, its costs now exceed the costs of all other public welfare/ developmental programs- including family assistance, Social Security Income, and the food stamp program. It was begun in 1965 and is now the nation's largest welfare program (Dye, 2008).
The Medicaid serves certain U.S. citizens and resident aliens, including low-income adults and their children, and people with certain disabilities. Poverty alone may not necessarily qualify someone for Medicaid. It covers almost one-third of the total child population, and deliveries also, most of them from families at or below the Federal poverty level. It also covers 8 million people with disabilities, and only one-fourth of the poor young adults, since their eligibility is higher. Medicaid also supports Medicare enrollees by paying their Medicare premiums and a few critical services that are not included in Medicare (The Kaiser Commision on Medicaid and the Uninsured, 2011).
The Program can be said to have served the maximum number of people, and when needed, like during the economic recession in the years of 2007-2009. The enrollment increased by nearly 6 Million during the Recession. This also put additional burden on the state budgets. The increased enrollment in-turn led to a rise an increase in the spending for Medicaid. It was of great help to the individuals who lost their jobs during this period and forced into poverty (The Kaiser Commission on Medicaid and the Uninsured, 2011).
Medicaid also helped the people in other ways, being a large source of the federal funding, and fuelling the economies of the states, and thus in turn increasing the number of jobs, like physician, pharmacists, nursing staff, and other auxiliaries.
Eligibility: The individuals or groups eligible for Medicaid are decided by the states. The eligibility groups will be considered one of the following (Medicaid At-a-Glance 2005 Medicaid Data Sources):
The Categorically needy,
The Medically needy, or
The Special groups.
A brief description of each of the key eligibility groups included is given, though these descriptions may not include all groups.
The Categorically Needy
Pregnant women and children under age 6 whose family income is at or below 133 % of the Federal poverty level.
Children ages 6 to 19 with family income up to 100% of the Federal poverty level.
Supplemental Security Income (SSI) recipients (or, in certain states, aged, blind, and disabled people who meet requirements that are more restrictive than those of the SSI program).
Individuals and couples who are living in medical institutions and who have monthly income up to 300% of the SSI income standard (Federal benefit rate).
The Medically Needy
The medically needy have too much money (and in some cases resources like savings) to be eligible as categorically needy. If a state has a medically needy program, it must include pregnant women through a 60-day postpartum period, children under age 18, certain newborns for one year, and certain protected blind persons.
States may also provide Medicaid to:
Children under age 19 who are full-time students can be categorized by deciding the age-limit
Caretaker relatives (relatives or legal guardians who live with and take care of children).
Aged persons (age 65 and older).
Blind persons (blindness is determined using the SSI program standards or state standards).
Disabled persons (disability is determined using the SSI program standards or state standards).
Persons who would be eligible if not enrolled in a health maintenance organization.
Medicare Beneficiaries-Medicaid pays Medicare premiums, deductibles and coinsurance for Qualified Medicare Beneficiaries (QMB)-individuals whose income is at or below 100% of the Federal poverty level and whose resources are at or below twice the standard allowed under SSI. There are additional groups for whom Medicare related expenses are paid by Medicaid-Medicare beneficiaries with income greater than 100% but less than 135% of the Federal poverty level (Medicaid At-a-Glance 2005 Medicaid Data Sources).
The Affordable Care Act
The Affordable Care Act, which was passed by the Congress and put into law by the President Barack Obama in March 2010, puts in place comprehensive health insurance reforms that will hold insurance companies more accountable, lower health care costs, guarantee more health care choices, and enhance the quality of health care for all Americans. The Act gives an individual better control of his own decisions about his health coverage, like, to get the health benefits through work, buy insurance for himself, or if he has small business and desires to provide health coverage to his employees, who are on Medicare, or do not have an insurance (About the Affordable Care Act / HealthCare.gov).
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This act soon makes insurance more affordable by providing small businesses with a tax credit to provide coverage, and by 2014, by providing tax credits to those who need help in buying insurance -- representing the largest middle class tax cut for health care in history (About the Affordable Care Act / HealthCare.gov). This Act was aimed at helping reduce the costs of insurance premiums for millions of American families and small business owners who are not eligible for the Medicaid, thus making health coverage affordable.
The Affordable Care Act will ensure that most of the uninsured individuals are brought under coverage by 2014, and if they do not have access to affordable employer coverage, they will be able to purchase through a health insurance exchange. It also imposes new regulations for employers who do not provide coverage for their employees, by levying new penalties and taxes, with exceptions for small employers. Medicaid may also be expanded to 133% of the Federal poverty level for all individuals under 65.
In spite of being the most successful public programs implemented by the government, the Affordable Care Act and the Medicaid programs had challenges. A few of them have illustrated here.
Though the Affordable Care Act is deemed to extend the health insurance coverage by both expanding Medicaid eligibility and offering premium subsidies for the purchase of private health insurance through state health insurance exchanges, the eligibility, by definition, for these programs is sensitive to income and can change over a period of time with fluctuating income and changes in family composition. Since the law specifies no minimum enrollment period, subsidy levels will also change as income rises and falls. (Benjamin D Sommers, 2011)
The author estimated using national survey data that within six months, more than 35 percent of all adults with family incomes below 200 percent of the federal poverty level will experience a shift in eligibility from Medicaid to an insurance exchange, or the reverse; within a year, 50 percent, or 28 million, will. The states and the federal government should adopt strategies to reduce the frequency of coverage transitions and to mitigate the disruptions caused by those transitions, so that it minimizes the effect on continuity and quality of care (Benjamin D Sommers, 2011).
The greatest achievement of the Affordable Care Act of 2010 has been its ability to deliver a guarantee of access to affordable health insurance. This is accomplished by the law through two principal pathways. The first being, expanding Medicaid eligibility to all nonelderly citizens and eligible legal residents whose family income does not exceed 133 percent of the federal poverty level, then, enabling Medicaid-ineligible people with incomes up to 400 percent of poverty to receive premium subsidies through tax credits for health plans offered through state health insurance exchanges (Benjamin D Sommers, 2011).
Though the Affordable Care Act helped subsidize the cost of health insurance, it had impact on income-related eligibility, because of the fluctuating incomes, and changing family sizes and compositions. As there was no specification in the Act, regarding minimum enrollment period, there was a constant change in the eligibility and subsidy levels with fluctuations in incomes. Moreover individuals are required to report changes in income frequently, more than once a year, thus eligibility can cease in any month.
This potential for movement between Medicaid and exchange coverage was discussed previously by many authors like Short. P F, Graefe. D R, & Schoen, C. in 2003, and Gerry Lynn Fairbrother, Heidi Park Emerson, Lee Partridge in 2007, can be thought of as an update to the classic problem of "churning" (frequent changes back and forth, in and out of Medicaid), a problem with which Medicaid has long grappled.
Thus, issues like these may cause a disruption in the Medicaid coverage within a short period. Though Affordable Care Act may be rectifying the total loss of coverage when the individual loses eligibility for Medicaid, by providing an alternative source of coverage, there have been challenges in the implementation of the two programs, like increasing the administrative costs. The author Benjamin D Sommers, also proved the increase in the administrative costs and also the adverse effects on the access to the health coverage.
There has also been a controversy in the public opinion regarding the Affordable Care Act, since it also made it necessary for all Americans to have coverage by the year 2014. And moreover, it had opposition from Political candidates such as Tim Pawlenty, a Republican, on his presidential campaign trail, tried to use the law's unpopularity for his benefit. He also said in one of his statements, that he would be repealing the acts, if he became the president. (Oliphant, 2011)
The author Benjamin D Sommers suggests some options for these issues:
Reduce likelihood of frequent eligibility changes: this may be achieved by setting a minimum eligibility period, the governments can use annual re-determination procedures rather than the frequent ones, in practice now.
This was recommended by the Medicaid Redesign team, have been brought about in the New York State Budget for the year 2011, like allowing the aged and permanently disabled with fixed incomes to be automatically renewed based on cost of living increases. Currently, Medicaid recipients must complete and mail-in a renewal form once a year in order to continue to receive health care coverage. (Medicaid RedesignTeam, 2011)
Another policy decision regarding the Act was established, that is introducing a standard 5% disregard in the income, furthermore expanding the Medicaid coverage, by raising the eligible income from 133% of poverty level to 138% of Poverty, which is to be implemented by 2014. Individuals with incomes between 139% and 400% of poverty, who are not covered by employer or any public plan, will be eligible for tax credits, if he buys private insurance through new state based Health insurance exchanges. (Focus on Health Reform, 2011)
Efforts should be made to align the markets and the provider networks in such a way, that they offer coverage under both plans.
The individuals facing the shifts between the programs should be supported appropriately.
Thus, these issues illustrate about how a policy, implemented by the government can have some advantages and disadvantages and affects the public, and how it is brought out in the limelight by the media. This illustrates the evaluation part of the policy making process, and how it was corrected by the government by implementing corrections to the program in the recent State Budget of New York State, for the year 2011,which can be considered as drafting a new policy again. A Public Policy is deemed to be successful when it serves the society without causing any further burden on the public and the government. And the media and the public should project such drawbacks and see that they are corrected by the government.
The Affordable Care Act and the Medicaid, were beneficial to the public in many ways, like they provided coverage to many uninsured, and also to those who were pushed into poverty because of the Economic Recession in years 2007-2009, and they covered many children and the child births, the elderly, and those conditions which were not covered by most of the private plans and the individual was not eligible for Medicaid, directly. They also became a large source of federal funds, providing employment and creating a market.
Though issues can rise in any major policy decisions, if they can be corrected, like the issues of eligibility, they will definitely prove more successful. Thus Policy making process can be called a never ending process, since issues keep on coming, in the process of their administration.
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