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Medicaid

Popular Medicaid Programs Do Battle With State Budget Pressures: Perspectives From Twelve States

Abstract

 
Many are concerned that growth of state Medicaid and State Children’s Health Insurance Program (SCHIP) spending, along with limited political clout among beneficiaries, make these programs extremely vulnerable in periods of serious state budget constraints. But observations based on Community Tracking Study site visits show that states have thus far largely avoided major cuts that would seriously harm beneficiaries’ access, primarily because programs have more support among coalitions of public officials, health care providers, and local advocates than commonly assumed. However, the limits to this surprising level of support are exemplified by decisions in many states to shelve some planned future expansions indefinitely.

By the end of 2001, however, the sluggish economy started to put states into a more precarious fiscal situation. In most states the combination of declining revenues and laws requiring balanced budgets forced policymakers to consider budget cuts. The rapid growth of Medicaid and SCHIP spending, attributable in part to the program expansions of the 1990s, and the large share of state budgets they represent made them obvious targets. But while states have tried to contain rising Medicaid costs by cutting or restricting some benefits, reducing provider fees, and slowing enrollment growth through higher premiums for some beneficiaries and reintroducing some administrative barriers, both the programs and the past decade’s expanded eligibility levels have been left largely intact.²

This comes in stark contrast to the prevailing view that Medicaid is destined to suffer in the legislative wars when budgets get tight. As a "poor people’s program," it is viewed as lacking strong political constituencies to sustain it in difficult times. But Larry Brown and Michael Sparer argue that Medicaid "has developed constituencies of sufficient breadth, depth, and clout to protect the program in hard times and to enlarge it when the clouds lift."³ Matching federal funds also give states a powerful financial incentive to maintain the program (since any cuts mean a loss of federal revenue), while state autonomy in administering the programs gives states the flexibility to make changes in the program that are consistent with their budget and policy environment. Nevertheless, the almost unprecedented scale of state budget woes and the increase in program spending have presented new challenges to the political sustainability of these programs.

In this study we examine the Brown-Sparer hypothesis as played out in recent budget cycles for the states where the twelve Community Tracking Study (CTS) sites are located. Consistent with this hypothesis, we show how some public officials sought to protect the programs. Key contributing factors were the growing number of constituencies with a stake in the safety net, fiscal opportunism on the part of states, and the flexibility to devise specific cost containment strategies to preserve eligibility gains achieved over the past decade.

We also examine the limits of this hypothesis—specifically, ways in which efforts to preserve recent Medicaid and SCHIP expansions often compete with other state policy imperatives, such as holding the line on new taxes, balancing the budget, and funding other priorities, which could pose future dangers for Medicaid if states’ fiscal problems continue. We also consider whether continued efforts to expand Medicaid and SCHIP are now in jeopardy as policymakers put aside new expansions in favor of preserving existing programs.

Our findings are based on data from the CTS site visits, conducted every two years beginning in 1996. The most recent round of visits (Round Four) occurred between September 2002 and May 2003. Researchers interviewed representatives of health care providers (both safety-net and mainstream), health plans, employers, local officials, advocates for low-income populations, and other community respondents. We also interviewed officials from state health or human services departments, representatives from the governor’s office, and state legislators.

Given most states’ fiscal situation, we identified state and local budget responses as a key policy focus for these visits. Interview protocols included specific questions on state budgets as well as more general questions on the status of the safety net and the broader health system in the communities. Although we studied policy responses in just twelve states, our approach permitted an in-depth examination of the decision-making processes regarding Medicaid and other public program cuts in these states, allowing us to assess both the depth and breadth of political support for these programs. Our interviews with community health care leaders allowed us to assess any early impacts of Medicaid cuts on communities.

Status Of State Budgets And Programs, 2003–04

Top Status Of State Budgets... Economic And Policy Context... Conclusions And Policy... Editor's Notes NOTES

 
Budgetary shortfalls. Ten of the twelve CTS states reported budget shortfalls for fiscal year 2003 in January 2003, the midpoint of our site visits. These deficits ranged from 1.2 percent of the general fund budget in Washington State to 11.0 percent in California (Exhibit 1). Seven states were forced to implement additional cuts after the FY 2003 budgets had already passed.⁴ Planning for FY 2004 proved to be an even greater challenge for state policymakers, as deficit estimates escalated—as high as 30 percent of the general fund budget in California. The exception is Arkansas, for which data show no budget shortfall in either year. However, during our site visit in January 2003, Arkansas officials noted a $100 million shortfall in the budget of the Department of Human Services, which operates Medicaid.

Proposed and enacted Medicaid cuts. The CTS states have attempted to contain Medicaid costs primarily by slowing the pace of enrollment and reducing provider payments. Fewer states have enacted measures that would directly impair patients’ access to services or reduce eligibility. Although many states considered proposals to reduce or eliminate program eligibility for certain groups, only a few enacted these changes. Furthermore, eligibility cuts enacted in one state (Arkansas) affected a small (although medically needy) population, while eligibility cuts in another (Massachusetts) were mostly restored by the legislature.

The most widely adopted type of cut was to slow the pace of enrollment by reducing outreach activities, reintroducing certain administrative barriers (such as decreasing the time for eligibility redetermination from twelve to six months), or freezing new enrollment. Although program supporters decried these changes, some local respondents acknowledged that these types of cuts would be easier to reverse when the budget crisis eases.

Furthermore, some respondents did not expect to see large effects from cutting outreach, because of the ability to capitalize on the results of major outreach efforts of the late 1990s, particularly for SCHIP. When eligibility for children was expanded, it was necessary to teach both families and providers about the new coverage. Local schools, providers, community and religious groups, and employers participated actively in the effort.⁶ This effort largely succeeded, and more targeted outreach may be adequate to accomplish today’s goals. As one state official said, "It was no longer an issue of finding the people who were eligible. People were clamoring to get in the program." As state funding is reduced, many community organizations continue outreach funded by other sources. Similarly, safety-net providers continue enrolling their patients, even though fewer state resources are available to support this effort.

Measures to make it harder for beneficiaries to complete required redeterminations of their eligibility may have a greater effect. Twelve-month continuous eligibility was eliminated in Arizona, Indiana, and Washington. Massachusetts reduced the time for a beneficiary to respond to a notice and stopped including a self-addressed stamped envelope and sending out two reminder notices. At the time of our Boston site visit, respondents already reported a drop in Medicaid enrollment as a result of the changes. Measures to cap or freeze program enrollment, as in Florida, may be more acceptable because they affect potential new enrollees rather than current ones. Further, they can be lifted more easily when the budget outlook improves.

In addition, several states have reduced provider payments, which may threaten beneficiaries’ access to certain providers. For example, respondents from Green-ville noted that because of a change in methodology resulting in lower Medicaid provider payment rates, providers were less willing to take Medicaid patients during the previous two years.

Finally, cuts in program administration affected access in at least two states. In Syracuse reduced funding for facilitated enrollment, coupled with increased demand for services, has strained enrollers and increased processing time for public program applications. Hiring freezes in Indianapolis have made it harder for enrollees to get services, ask questions, and enroll in programs.

Across the sites, we saw only limited impact from the budget cuts. This was in part a matter of timing. At the time of our visits, states had not finalized their budgets for FY 2004; most were involved in intense negotiations over potential cuts to public insurance programs. Local respondents in the twelve sites varied in their level of concern over the potential cuts. In at least one site (Indianapolis) the prospects of state budget retrenchment and lower revenues from Medicaid led safety-net providers to try to become more efficient, streamline operations, diversify their funding bases, and become more aggressive about collecting copayments.⁷ But few sites had felt any actual effects of previous program reductions. In fact, respondents in most sites had more to say about the benefits of the earlier program expansions than about the prospects of possible program cuts.

Program expansions. Despite program cuts, attention to program expansions did not completely disappear. At least five CTS states took advantage of the new opportunity provided by the federal government to cover certain women diagnosed with breast or cervical cancer. In Arkansas, coverage for pregnant women was expanded to include those with incomes up to 200 percent of poverty (up from 133 percent), starting in 2002. Washington increased fee-for-service provider payment rates, and New York raised rates for physician office visits in 2000.

Some eligibility expansions were approved but rescinded under budget pressure. California, for example, postponed until 2006 its expansion of Medi-Cal to cover more parents of children already on the program. Indeed, shelving plans for further public program expansions indefinitely may be the single biggest effect of states’ budget crises. Nevertheless, such decisions may reflect a belief that it was better to deny newly eligible people the opportunity to sign up for the program than to remove those already receiving benefits from the rolls.

Economic And Policy Context Of Program Changes

Top Status Of State Budgets... Economic And Policy Context... Conclusions And Policy... Editor's Notes NOTES

 
Each of the twelve CTS states was unique in how decisions on public program changes were made, and the reasons for these changes. Here we explore the role of various economic and political factors in the decisions. Our findings provide support for the idea that Medicaid and SCHIP benefit from "constituencies of sufficient breadth, depth, and clout to protect the program in hard times."⁸ On the other hand, broad political support for Medicaid and SCHIP is not enough to shield them completely from painful cuts, and other competing objectives of state government mean that protection of these programs in the future is not guaranteed.

Role of public officials. In many CTS sites, public officials from both political parties have enthusiastically embraced Medicaid and SCHIP expansions, even to the extent of pushing through tax increases in some states. This support has greatly contributed to maintaining the programs.

Arkansas. The experience of Arkansas provides a good illustration of the role of public officials. Arkansas traditionally had one of the weaker Medicaid programs, despite high matching rates for federal funds. For years the state generally restricted its program to federally mandated populations. In 1997, however, the state received federal approval to create ARKids First, which offered coverage to children up to 200 percent of poverty. By 2003 about 235,000 children were enrolled, including both the traditional Medicaid segment and the expansion piece. Key to the program’s creation was the enthusiastic support of both Gov. Mike Huckabee and the broader health care community.

The governor, who regards the program as one of his major successes, was also crucial in protecting it from major cuts in 2003. Although Arkansas’ budget situation for FY 2004 was nowhere near as bad as in most other states, the state still had a hole to fill (roughly $100 million), which was threatening the status quo of state-funded programs. Initially, the legislature adjourned without filling this hole, leading the administration to list program cuts it would make to balance the budget in the absence of legislative action. The largest proposed cut would have lowered eligibility for ARKids First from 200 percent of poverty to 150 percent, affecting 40,000 children. Alternatively, the governor proposed new taxes on cigarettes, other tobacco products, and individuals’ incomes to fund the anticipated shortfall. In May 2003 the legislature returned and approved the new taxes, to preserve existing eligibility levels in ARKids First.

Arizona. The environment in Arizona was quite different. Term limits resulted in a more conservative and inexperienced legislature and a new governor. This appears to have depleted state health policy leadership and caused a loss of critical institutional knowledge around publicly sponsored health programs and the rationale for their creation and continued operation. For example, some respondents expressed frustration at the legislature’s proposal to eliminate SCHIP because legislators seemed not to understand that this move would cause the state to give back money to the federal government under SCHIP’s federal matching payment rules (in this case, the federal government pays 75 percent of the program’s cost). Ultimately, Gov. Janet Napolitano vetoed elimination of the program for children, but she did let stand elimination of eligibility for parents, major new premiums, enrollment fees, and copayments for enrolled children.⁹

Other states. In other states the legislative leadership rescued public programs from cuts that might have been deeper. In Massachusetts, despite a long tradition of generous support for public programs and eventual universal coverage, a new governor was willing to make cuts in Medicaid to avoid raising taxes. But the legislature restored many of these cuts. In New York, facing one of the largest deficits of our study states, Gov. George Pataki proposed more than $1 billion in health care cuts for the 2003–04 budget. These included a reduction in eligibility for its Medicaid expansion program and some cuts in provider payments. Ultimately, the legislature voted overwhelmingly to override the governor’s vetoes and approve a budget that raises sales and income taxes and essentially maintains health care spending. To cover its state deficit, Florida’s Gov. Jeb Bush proposed to end the medically needy program, which serves 27,000 enrollees. However, the legislature acted to provide new state spending to maintain the program at least temporarily. The state paid for the restored cuts with part of a Medicaid fraud settlement, federal matching dollars, and a freeze on new SCHIP enrollment.¹⁰

Health care providers. Many health care providers, especially those who serve a disproportionately high number of low-income and uninsured patients, are concerned about the effects of Medicaid cuts on their financial viability. This concern is broader than simply opposing cuts to provider payment rates; it also extends to eligibility and benefit cuts, which could further reduce providers’ revenue and increase uncompensated care costs. In Little Rock, for example, area hospitals reported large reductions in the amount of uncompensated care they provide to children since the expansion of the ARKids program and said that improved coverage for children has made it easier for them to provide charity care to uninsured adults. As a result, they opposed cuts to program eligibility.

Massachusetts illustrates how concern by key health care providers about the impact of Medicaid cuts on their own financial viability helped galvanize their opposition to the cuts. Because of budget shortfalls and a campaign promise by the new governor (Mitt Romney) not to raise taxes, about 36,000 beneficiaries of MassHealth Basic (one piece of the state’s combined Medicaid/SCHIP program) were eliminated from eligibility. The beneficiaries who lost coverage represented less than 5 percent of the overall Medicaid enrollment and were generally chronically unemployed adults, including a large number of substance abusers. Children and other more politically viable beneficiaries were spared from these cuts.

Despite the low political appeal of those who lost coverage in Massachusetts, their eligibility was eventually restored. Along with the timely infusion of new federal funds as a result of the federal tax legislation, broad support in the Boston health care community was key to restoring coverage. Since many of those losing coverage would continue receiving care for their health problems, providers expected their uncompensated care costs to increase. Although the state’s uncompensated care pool reimburses hospitals for these costs, the pool was also experiencing budgetary shortfalls. Since the pool is financed by an assessment on all hospitals (including those with no substantial uncompensated care costs) and a surcharge on health insurance premiums, concern about any rise in uncompensated care costs extended well beyond those safety-net providers who might be immediately affected. Major cuts in eligibility were avoided because of the mutual interests of health care providers and other advocacy groups, together with an infusion of federal funds and political leaders’ willingness to compromise.

Provider pushback was also a key factor in other states. New York (like Massachusetts) points out that health care jobs are vital to the state’s economy. As a result, the state’s hospitals and other providers were active in fighting Medicaid cuts, not only cuts in provider reimbursement where their stake was obvious, but also cuts in eligibility levels where their stake was less direct. In South Carolina the medical society was a strong advocate of using the tobacco tax to fend off Medicaid cuts. The society worked hard to advance this position, developing rapport between physicians and policymakers through annual "meet and greet" sessions and regular lobbying by both the medical society and specialty groups.

Role of local advocates. The coalition of support behind Medicaid in most states goes far beyond the low-income people who benefit most directly from the program. Low-income beneficiaries traditionally do not send well-funded, savvy lobbyists to the state legislature. Further, they are perceived as being less likely than others to participate in elections and are thus more easily ignored by legislators. In some communities, however, strong advocates for this population make up for what they lack in funding with enthusiasm on behalf of their causes.

The most effective advocacy organizations are those that formed coalitions with other groups with mutual interests. In Massachusetts, Health Care for All worked effectively in the mid-1990s to bring together behind the universal health care effort the various constituencies that could benefit. In the recent budget debates, they played a similar role in organizing a coalition of interested groups, including providers, which were key in restoring some of the Medicaid cuts.

Similarly, a strong cadre of senior health and human service advocates in Ohio was instrumental in getting the state to cover parents below 100 percent of poverty under SCHIP. They were pushing for coverage up to 150 percent of poverty when the state entered into its fiscal crisis. Advocates dropped their proposal to focus on maintenance of the program, rather than expansion, when Gov. Bob Taft proposed to reduce the eligibility level to 70–90 percent of poverty, depending on family size. Ultimately, the legislature approved a budget that maintained parental coverage at 100 percent of poverty. One state senator told us that the presence of strong, united advocates has been a huge advantage in maintaining support for Medicaid.

Finally, New Jersey’s Gov. James McGreevey generally avoided proposing any cuts for children in the Family Care program, one of the most generous in the country, with coverage up to 350 percent of poverty. Instead, he proposed a cut in eligibility for parents that would have removed 60,000 parents from the program. He also proposed a preferred drug list that would have limited access to prescriptions under Medicaid and cuts to dental benefits for disabled adults. The proposals brought protests from a coalition of advocacy groups and health professionals. In the end, the budget spared the program from most of the proposed cuts, although enrollment of parents remains frozen.

Fiscal opportunism. Over the years, many states have proved quite skilled at seizing opportunities to use creative fiscal measures to stave off budget cuts or tax increases. For a single year, states often use prior-year surpluses or rainy-day funds to balance their budgets. But respondents in most states told us that these measures had been exhausted in balancing budgets for FY 2002 or 2003. Several states had also drawn on their tobacco settlement funds to maintain health and other programs. Depending on how they used these funds, they sometimes offered potential help in future years as well. But as deficits grew, these funds often fell short. New York’s legislature opted to securitize its tobacco settlement revenue (worth $4.2 billion) after pledging general revenue funds in case future funds were insufficient to pay the bonds. New Jersey and South Carolina have also opted to securitize part of their tobacco settlements to increase revenues in the short term.

The fiscal relief provisions included in the federal Jobs and Growth Tax Relief Reconciliation Act of 2003 provided a new opportunity for the states. Although these funds arrived too late to help the budget process in many states, Massachusetts legislators capitalized on their availability to restore Medicaid cuts, as described above. Ohio was able to abandon a proposal to cut from Medicaid 50,000 working parents with incomes below poverty and to maintain a number of optional services for adults. California used its $2.4 billion in federal funds to fund programs that were previously slated for cuts in the governor’s budget.¹¹

Several states looked to creative maneuvers to find new revenues. Officials in Florida and Massachusetts, for example, identified new ways to generate federal Medicaid matching funds with intergovernmental transfers. Although the federal government acted a couple of years ago to curtail some uses of these fiscal schemes, other uses remain legal. Policymakers in Washington State were looking at the use of proceeds from the possible conversion to for-profit status of the local Blue Cross plan. Doing so would be controversial, since many advocates would prefer either that conversions not occur or that funds be made available to foundations that could use them for special projects over many years rather than a one-time budget rescue. This conversion has not yet occurred.

Finally, states sometimes found creative ways to redefine spending. California "saved" approximately $930 million by revising its Medicaid accounting practices. The revision delays the date when Medicaid considers a medical bill, which will shift some expenses from the current fiscal year to the next one.¹²

Raising taxes and tuition. In many CTS states, raising taxes was a more palatable option for some policymakers than cutting Medicaid services. As described above, Arkansas and New York eventually raised taxes to maintain Medicaid benefits. The Florida legislature raised fees and college tuition to cover the deficit. This helped to avoid a proposed elimination of the Medicaid medically needy program in Florida, although enrollment in Kidcare (the state’s SCHIP program) was frozen. South Carolina residents and Senate members showed strong support for an increased tobacco tax. The coalition leading the effort pushed for a fifty-three-cent-per-pack increase to provide stable Medicaid funding, and state economists estimated that the tax would provide about $171 million in new funds for Medicaid. However, the governor stated that he would support the cigarette tax only if income taxes were cut, and the measure was defeated.

Competition with other policy priorities. The positive effects of broad constituencies of support and fiscal creativity may be limited when they run up against other policy priorities. Nearly all states require balanced budgets, which precludes deficit spending to preserve public programs, although procedures in some states effectively allow some deficit spending. Although new federal funds and fiscal creativity by some states helped to forgo cuts at least temporarily, firm commitments to no new taxes in states such as Massachusetts and California severely limit the potential for new sources of revenue to maintain programs. The short-term nature of the new federal funds and some creative fiscal maneuvers mean that pressures will recur in the next budget cycle and that deficits could be even larger. Health programs also compete for limited funds with other policy priorities, such as education in Florida, Arkansas, and Washington; a crisis in the transportation system in Washington; and economic development in Arizona.

Although countervailing factors have thus far not been strong enough to result in major health program cuts, their main effect has probably been to stall prospects for any new expansions (as in Ohio) or to limit the growth of existing programs. Many states (such as Michigan and Indiana) deferred or abandoned plans to expand Medicaid and SCHIP eligibility to some adult groups, especially parents. Similarly, a 2000 referendum in Arkansas would have expanded eligibility to 40,000 additional adults, but that expansion was limited because of budget constraints. Thus, if examined from the perspective of gains achieved over the past decade, the effects of the state fiscal crisis on public programs so far appear to be minimal. However, if examined from the perspective of planned expansions that states had to shelve, the impact is much more severe.

Conclusions And Policy Implications

Top Status Of State Budgets... Economic And Policy Context... Conclusions And Policy... Editor's Notes NOTES

 
The CTS site visits provide strong support for the notion that broad political backing for Medicaid and SCHIP, coupled with timely financial incentives from the federal government, has greatly contributed to protecting recent program expansions from devastating cuts thus far. That these programs have been protected despite being major contributors to states’ budget deficits is further evidence of their political viability. The political popularity of programs for children, in particular, often kept them away from the budget axe completely. But cuts aimed at other populations were also spared in many cases, as illustrated by the decision in Massachusetts to restore coverage for a group of chronically unemployed adults.

Another contributing factor is the system of matching federal funds, which forces a state to cut services by two to four dollars to get a dollar of fiscal savings from Medicaid and SCHIP, whereas for most other programs, a dollar of cuts yields closer to a dollar in savings. If policymakers choose to make Medicaid cuts, they will have to bear the full brunt of alienating program supporters but get only partial fiscal benefit.

Although the twelve states in our study reflect a broad cross-section of states of varying sizes, regions, party affiliations of governors and state legislatures, and population characteristics, the experiences of some states not included in our study may be different. For example, a recent survey of officials in all fifty states reported that twenty-five had reduced or restricted eligibility for FY 2003, and eighteen had reduced benefits.¹³ Furthermore, cuts in some states (such as Texas) were far more severe than those experienced in the twelve CTS states. On the other hand, our in-depth analysis of the decision-making process in these states showed that many cuts in public programs could have been far worse. This is consistent with not only Brown and Sparer but other recent studies as well.¹⁴

Given the almost unprecedented scale of states’ fiscal woes, Medicaid and SCHIP expansions would almost certainly have been targeted for the earliest and most severe cuts if they were simply viewed as "poor people’s programs" without broad political support, as is often believed. Some local respondents feared the worst. In Boston one safety-net provider mentioned holding "doomsday meetings" in anticipation of massive cuts. In the end, cuts were more modest than expected.

Nevertheless, Medicaid and SCHIP have not been entirely spared from the budget axe, and their protected status thus far is not without limits. While deep cuts in eligibility, especially for children and traditional Medicaid beneficiaries, have been avoided, states have reduced provider payment, trimmed benefits, imposed cost sharing, and made enrollment procedures more difficult, all of which can deny access to health care services for people who depend on these programs. As Donna Ross and Laura Cox noted, "A different scenario also was unfolding that suggests the coverage expansions and streamlined procedures—as well as the increased enrollment they spurred—could be fragile."¹⁵

Since "do no harm" was not an option for most states, the approach appears to be "do as little harm as possible." States often chose the types of cuts (reduced outreach or stricter criteria for redetermining eligibility) that can be restored without legislative intervention when the fiscal outlook improves. Alternatively, they chose to cancel planned expansions or eliminate newly created benefits or provider payment increases, where high expectations on the part of beneficiaries and providers were not yet well established.

The future remains uncertain. Public opinion surveys consistently show strong public support for continued coverage expansions, although it is less clear that they are willing to bear the cost in the form of higher taxes.¹⁶ Chastened by recent experiences and rising program costs, states may opt to continue stringent cost containment activities to protect against future deficits. Without infusions of substantial new revenues from the federal government or elsewhere, a return to the recent days of program expansions seems unsure for the foreseeable future.

Nevertheless, our expectations are that states will strive to avoid making damaging cuts to Medicaid and SCHIP. The programs have a stronger foundation than conventional wisdom holds, as shown by consistent public support for program expansions. Providers have become strong backers, often teaming with other advocates to educate policymakers that cutting public program funding often results in increased uncompensated care. These forces may not always be adequate to overcome the challenges inherent in balancing a budget, but in 2002 and 2003 most states were able to minimize the harm done.

Editor's Notes

Top Status Of State Budgets... Economic And Policy Context... Conclusions And Policy... Editor's Notes NOTES

 
This research was conducted as part of the Center for Studying Health System Change’s Community Tracking Study, which is funded by the Robert Wood Johnson Foundation. The authors gratefully acknowledge the work of their research team: Aaron Katz, Suzanne Felt-Lisk, Larry Brown, Laurie Felland, and Andrea Staiti. They also thank Brown, Felland, Paul Ginsburg, Kyle Kinner, and two anonymous reviewers for their valuable comments.

Jack Hoadley (jfh7{at}georgetown.edu) is a research professor at Georgetown University’s Health Policy Institute in Washington, D.C. Peter Cunningham is a senior health researcher at the Center for Studying Health System Change, also in Washington. Megan McHugh is a research analyst at Mathematica Policy Research in Washington.

NOTES

Top Status Of State Budgets... Economic And Policy Context... Conclusions And Policy... Editor's Notes NOTES

 

1. D.C. Ross and L. Cox, Preserving Recent Progress on Health Coverage for Children and Families: New Tensions Emerge (Washington: Kaiser Commission on Medicaid and the Uninsured, July 2003).
2. Ibid.; and D.J. Boyd, "The Bursting State Fiscal Bubble and State Medicaid Budgets," Health Affairs (Jan/Feb 2003): 46–61.
3. L.D. Brown and M.S. Sparer, "Poor Program’s Progress: The Unanticipated Politics of Medicaid Policy," Health Affairs (Jan/Feb 2003): 38.
4. National Governors Association and National Association of State Budget Officers, "The Fiscal Survey of States" (Washington: NGA and NASBO, November 2002).
5. NGA and NASBO, "The Fiscal Survey of States" (Washington: NGA and NASBO, June 2003).
6. L.E. Felland and A.M. Benoit, Communities Play Key Role in Extending Public Health Insurance to Children, Issue Brief no. 44 (Washington: Center for Studying Health System Change, October 2001).
7. Such steps by safety-net providers were not a new development in response to the budget situation. Many providers had initiated efforts to become more efficient or diversify funding during the years when budgets were more flush. See L. Felland et al., The Health Care Safety Net: Money Matters but Savvy Leadership Counts (Washington: HSC, August 2003).
8. Brown and Sparer, "Poor Program’s Progress."
9. A. Short et al., Population Growth, Economic Downturn Stress Phoenix’s Health Care Capacity (Washington: HSC, Summer 2003).
10. J. James, "Rivaling State Budget Proposals Move Forward," Miami Herald, 17 April 2003.
11. Ross and Cox, Preserving Recent Progress; and A. Katz et al., HMOs Alive and Well in Orange County (Washington: HSC, Summer 2003).
12. C. Berthelsen and J. Wildermuth, "Governor Blames GOP for Cuts as His Recall Poll Numbers Worsen," San Francisco Chronicle, 3 August 2003.
13. V. Smith et al., States Respond to Fiscal Pressure: State Medicaid Spending Growth and Cost Containment in Fiscal Years 2003 and 2004: Results from a Fifty-State Survey (Washington: Kaiser Commission on Medicaid and the Uninsured, September 2003).
14. Ross and Cox, Preserving Recent Progress; and J. Fossett and C. Burke, Is Medicaid Retrenching? State Budgets and Medicaid Enrollment in 2002 (Albany: Nelson A. Rockefeller Institute of Government, February 2003).
15. Ross and Cox, Preserving Recent Progress, 2.
16. R.J. Blendon, J.M. Benson, and C.M. DesRoches, "Americans’ Views of the Uninsured: An Era for Hybrid Proposals," Health Affairs, 27 August 2003, content.healthaffairs.org/cgi/content/abstract/hlthaff.w3.405 (11 December 2003).

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