NOTES



The Twentieth Century Fund was aided in preparation of this guide by Cindy Mann of the Center on Budget and Policy Priorities, Melvina Ford of the Congressional Research Service, Martcia Wade of the Urban Institute, Kristina Hanson of the Kaiser Commission on the Future of Medicaid, and Julie Darnell of the Center for Health Policy Research of George Washington University. They all reviewed material and provided additional information cheerfully and efficiently.



  1. The numbers presented in this report are preliminary and are subject to change based on the final legislation. Moreover, modifications in the assumption about balancing the budget would alter the figures. [Return to text]

  2. Jennifer L. Howse, president, March of Dimes Birth Defects Foundation, "Medicaid Benefits and Effectiveness in Improving Maternal and Child Health," testimony before the Committee on Labor and Human Resources, U.S. Congress, Senate, 104th Cong., 1st sess., August 1, 1995, p. 3. [Return to Text]

  3. The expenditure and recipient data in this report were prepared by the Urban Institute, one of the foremost authorities on health care policy. The calculations were based on the Health Care Financing Administration's forms 2082 and 64. [Return to Text]

  4. John Holahan, Colin Winterbottom, and Shruti Rajan, The Changing Composition of Health Insurance Coverage in the United States (Washington, D.C.: Urban Institute, January 1995). [Return to Text]

  5. U.S. Department of Health and Human Services, Health Care Financing Administration, 1995 Data Compendium (Baltimore: Health Care Financing Administration, 1995). [Return to Text]

  6. Diane Rowland, senior vice president, The Henry J. Kaiser Family Foundation, "Directions for Health Reform," testimony before the Committee on Labor and Human Resources, U.S. Congress, Senate, 104th Cong., 1st sess., March 15, 1995. [Return to Text]

  7. Kaiser Commission on the Future of Medicaid, Medicaid and Federal, State, and Local Budgets (Washington, D.C.: Kaiser Commission on the Future of Medicaid, 1995), p. 7. [Return to Text]

  8. Ibid. [Return to Text]

  9. National Association of State Budget Officers, 1994 State Expenditure Report (Washington, D.C.: NASBO, 1995), pp. 9, 71, 93. [Return to Text]

  10. Nancy De Lew, "The First 30 Years of Medicare and Medicaid," Journal of the American Medical Association 274 (1995), p. 266. [Return to Text]

  11. Howse, "Medicaid Benefits and Effectiveness in Improving Maternal and Child Health," testimony before the Committee on Labor and Human Resources, p. 3. [Return to Text]

  12. Congressional Research Service, Medicaid: An Overview (Washington, D.C.: U.S. Government Printing Office, 1993), p. 51. [Return to Text]

  13. National Governors' Association, "State Medicaid Coverage of Pregnant Women and Children," in MCH Update, Washington, D.C., September 1995. [Return to Text]

  14. Ibid. [Return to Text]

  15. Robin Toner, "Critics Say Republican Budget Will Create Shortage of Nursing Home Beds for Elderly," New York Times, November 12, 1995, section I, p. 30. [Return to Text]

  16. Ibid. [Return to Text]

  17. De Lew, "First 30 Years of Medicare and Medicaid," p. 266. [Return to Text]

  18. Paul W. Newacheck et al., "The Effect on Children of Curtailing Medicaid Spending," Journal of the American Medical Association 274, no. 18 (November 8, 1995): 1470. [Return to Text]

  19. "Medicaid and the States: Recent Growth in Medicaid Costs," Urban Institute Policy and Research Report 25, no. 1 (Winter­Spring 1995): 19. [Return to Text]

  20. Melvina Ford, specialist in social legislation, Congressional Research Service, Education and Public Welfare Division, interview with Sarah Ritchie, program officer at the Twentieth Century Fund, December 4, 1995. [Return to Text]

  21. U.S. Department of Commerce, Bureau of the Census, Statistical Abstract of the United States 1994 (Washington, D.C.: U.S. Government Printing Office, 1994), p. 75. [Return to Text]

  22. According to a recent report by Families USA, a health advocacy group, the infant mortality rate showed a marked reduction (20 percent decline) between 1984 and 1992, the period in which Congress expanded Medicaid coverage for pregnant women and children. See Families USA, Hurting Real People: The Human Impact of Medicaid Cuts (Washington, D.C.: Families USA, 1995), p. 11. [Return to Text]

  23. De Lew, "First 30 Years of Medicare and Medicaid," p. 266; Newacheck et al., "Effect on Children of Curtailing Medicaid Spending," p. 1469. [Return to Text]

  24. Kristin Moore, executive director of Child Trends, interview with Sarah Ritchie, program officer at the Twentieth Century Fund, October 30, 1995. [Return to Text]

  25. U.S. General Accounting Office, Medicaid Prenatal Care: States Improve Access and Enhance Services but Face New Challenges (Washington, D.C.: U.S. Government Printing Office, May 1994), p. 24. [Return to Text]

  26. Trish Riley, "Medicaid: The Role of the States," Journal of the American Medical Association 274, no. 3 (July 19, 1995):269; for a complete listing of optional services state-by-state, see Congressional Research Service, Medicaid: An Overview, p. 257. [Return to Text]

  27. The Kaiser Commission on the Future of Medicaid, Access to Health Care: Is Health Insurance Enough? (Washington, D.C.: Kaiser Commission on the Future of Medicaid, 1995), p. 3. [Return to Text]

  28. Ibid. [Return to Text]

  29. The Kaiser Commission on the Future of Medicaid, Medicaid at the Crossroads (Washington, D.C.: Kaiser Commission on the Future of Medicaid, 1992), pp. 28­29. [Return to Text]

  30. Ibid. [Return to Text]

  31. Kaiser Commission, Access to Health Care, p. 4. [Return to Text]

  32. Physician Payment Review Commission, Annual Report to Congress, 1995 (Washington, D.C.: Physician Payment Review Commission, 1995), pp. 163­64. [Return to Text]

  33. Howse, "Medicaid Benefits and Effectiveness in Improving Maternal and Child Health Care," testimony before the Committee on Labor and Human Resources, pp. 1­2. [Return to Text]

  34. De Lew, "First 30 Years of Medicare and Medicaid," p. 267. [Return to Text]

  35. Diane Rowland, "Medicaid at 30: New Challenges for the Nation's Health Safety Net," Journal of the American Medical Association 274, no. 3 (July 19, 1995):272. [Return to Text]

  36. Riley, "Medicaid: The Role of the States," p. 268. [Return to Text]

  37. Ibid. This information was updated by Julie Darnell, research associate, Center for Health Policy Research at George Washington University, November 26, 1995. [Return to Text]

  38. Mark Merlis, "Medicaid: An Overview," Congressional Research Service Report no. 93­144 EPW, Washington, D.C., 1993, p. 26. [Return to Text]

  39. Congressional Research Service, Medicaid: An Overview, p. 488. [Return to Text]

  40. Bruce C. Vladeck and Kathleen M. King, "Medicare at 30: Preparing for the Future," Journal of the American Medical Association 274, no. 3 (July 19, 1995): 260. [Return to Text]

  41. Newacheck et al., "The Effect on Children of Curtailing Medicaid Spending," p. 1470. [Return to Text]

  42. Physician Payment Review Commission, Annual Report to Congress, 1995 p. 12. [Return to Text]

  43. See note 3. [Return to Text]

  44. De Lew, "First 30 Years of Medicare and Medicaid," p. 263. [Return to Text]

  45. National Association of State Budget Officers, 1994 State Expenditure Report, p. 16. [Return to Text]

  46. Kaiser Commission on the Future of Medicaid, Medicaid and Federal, State, and Local Budgets, p. 10. [Return to Text]

  47. National Association of State Budget Officers, 1994 State Expenditure Report, pp. 1­7. [Return to Text]

  48. "Medicaid and the States: Recent Growth in Medicaid Costs," p. 18. [Return to Text]

  49. The 68 percent figure excludes spending for DSH programs. [Return to Text]

  50. Martcia Wade and Kathleen Adams, Analysis of the Recent Expansions in Medicaid Costs (Washington, D.C.: Urban Institute, July 1994), p. 2. [Return to text]

  51. U.S. Department of Commerce, Bureau of the Census, Statistical Abstract of the United States 1994 (Washington, D.C.: U.S. Government Printing Office, 1994), p. 16. These figures are based on the middle-series projections. Additional data was provided by the U.S. Census Bureau Report, P25­1104. [Return to Text]

  52. The Kaiser Commission on the Future of Medicaid, Health Needs and Medicaid Financing: State Facts (Washington, D.C.: Kaiser Commission on the Future of Medicaid, 1995), p. 5. [Return to Text]

  53. Congressional Research Service, Medicaid: An Overview, p. 3. [Return to Text]

  54. Kaiser Commission on the Future of Medicaid, Medicaid at the Crossroads, pp. 40­41. [Return to Text]

  55. Kaiser Commission on the Future of Medicaid, Access to Care: Is Health Insurance Enough?, p. 7. [Return to Text]

  56. U.S. General Accounting Office, Medicaid: A Program Highly Vulnerable to Fraud (Washington, D.C.: U.S. Government Printing Office, February 1994). [Return to Text]

  57. Riley, "Medicaid: The Role of the States," p. 269. [Return to Text]

  58. Rowland, "Medicaid at 30," p. 272. [Return to Text]

  59. Diane Rowland et al., Medicaid and Managed Care: Lessons from the Literature (Washington, D.C.: Kaiser Commission on the Future of Medicaid, March 1995), p. 18. [Return to Text]

  60. Rowland, "Medicaid at 30," p. 272. [Return to Text]

  61. Jane Horvath, "Medicaid: Successes, Failures, and Prospects," Intergovernmental Relations 18, no. 2 (Spring 1992): 12­14. [Return to Text]

  62. Riley, "Medicaid: The Role of the States," p. 268. [Return to Text]

  63. On one hand, state policymakers were behaving entirely in an economically rational way by maximizing federal funds for their state coffers. However, this strategy has serious flaws in terms of the distribution of funds by the federal government. [Return to Text]

  64. Wade and Adams, Analysis of the Recent Expansions in Medicaid Costs, pp. 1­8. [Return to Text]

  65. Leighton Ku and Teresa Coughlin, Medicaid Disproportionate Share and Other Special Financing Programs: A Fiscal Dilemma for States and the Federal Government (Washington, D.C.: Urban Institute, December 1994); unpublished data from the Urban Institute. [Return to Text]

  66. U.S. General Accounting Office, Medicaid: States Use Illusory Approaches to Shift Program Costs to Federal Government (Washington, D.C.: U.S. Government Printing Office, August 1994). [Return to Text]

  67. This statistic is cited by a press release made by the American College of Physicians, Philadelphia, October 23, 1995. Estimates of reduced enrollment by the Urban Institute vary from 3.8 million to 8 million. [Return to Text]

  68. Families USA, Hurting Real People, p. 3. [Return to Text]

  69. Newacheck et al., "The Effect on Children of Curtailing Medicaid Spending," pp. 1468­71. [Return to Text]

  70. See Families USA, Hurting Real People, pp. 32­33. [Return to Text]

  71. Clifford M. Johnson, "Why Block Grants Would Be Disastrous for America's Children," in The Finance Project and American Youth Policy Forum and the Policy Exchange, Dollars and Sense: Diverse Perspectives on Block Grants and the Personal Responsibility Act (Washington, D.C.: Finance Project, 1995), p. 41. [Return to Text]

  72. Steven D. Gold, "The ABCs of Block Grants," State Fiscal Brief (Albany), March 1995. [Return to Text]

  73. Of these states, eleven passed "significant" tax cuts in excess of 1 percent of the prior year's revenue. This information is based on the forthcoming edition of the National Conference of State Legislatures, State Tax Actions (Denver: NCSL, forthcoming). [Return to Text]

  74. The study was conducted by the research firm Lewin/VHI for the "Leadership Coalition" and was cited by Howard Shapiro, director of Public Policy for the American College of Physicians in a press release, Philadelphia, October 23, 1995. [Return to Text]

  75. Steven D. Gold and Sarah Ritchie, "State Actions Affecting Cities and Counties, 1990­93: De Facto Federalism," Center for the Study of the States, Albany, 1994. [Return to Text]

  76. Larry S. Gage, president, National Association of Public Hospitals, testimony before the Subcommittee on Health and the Environment, U.S. Congress, House, Committee on Commerce, 104th Cong., 1st sess., August 1, 1995, p. 8. [Return to text]

  77. For an explanation, see Paul E. Peterson, City Limits (Chicago: University of Chicago Press, 1981). [Return to text]

  78. Paul E. Peterson and Mark C. Rom, Welfare Magnets: A New Case for a National Standard (Washington, D.C.: Brookings Institution, 1990). More recently, see Paul E. Peterson, Mark C. Rom, and Kenneth F. Scheve, Jr., "State Welfare Policy: A Race to the Bottom?" manuscript prepared for the 1995 National Association for Welfare Research and Statistics Annual Research Conference. See also "Medicaid: The Distribution Formula," testimony of Paul E. Peterson, Henry Lee Shattuck Professor of Government, Harvard University, before the Finance Committee, U.S. Congress, Senate, 104th Cong., 1st sess., July 27, 1995. [Return to text]

  79. The interstate variation of funding for social services, including Medicaid, can clearly be demonstrated. Expenditures do not necessarily represent policy successes or outcomes. However, many would argue that large interstate variations in expenditures for indigent health care do represent differences in the services delivered. [Return to text]

  80. Richard Kogan, Cindy Mann, and Myra Tanamor, "State-by-State Effects of the Federal Medicaid Cuts Proposed in the Reconciliation Bill," Center on Budget and Policy Priorities, November 20, 1995. [Return to text]

  81. In addition to the federal funds for poor patients, public hospitals also receive federal money to train residents from foreign medical schools. The Medicare plan passed recently in the House eliminates this assistance. See Amy Goldstein, "Suffering the Consequences: Public Hospitals Would Be the Loser in Medicare and Medicaid Cuts," Washington Post Weekly Edition, October 30­November 5, 1995, pp. 6­7. [Return to text]

  82. Charles Brecher and Sheila Spiezio, Privatization and Public Hospitals: Choosing Wisely for New York City(New York: Twentieth Century Fund Press, 1995). [Return to text]

  83. Theodore R. Marmor, Jerry L. Mashaw, and Philip L. Harvey, America's Misunderstood Welfare State: Persistent Myths, Enduring Realities (New York: Basic Books, 1990), pp. 47­48. [Return to text]

  84. Many surveys from the Roper and Gallup organizations, for instance, report these findings. For a review, see Robert S. Erikson and Kent L. Tedin, American Public Opinion: Its Origins, Content, and Impact, 5th ed. (Needham Heights, Mass.: Allyn and Bacon, 1995), p. 90; Benjamin I. Page and Robert Y. Shapiro, The Rational Public: Fifty Years of Trends in Americans' Policy Preferences (Chicago: University of Chicago Press, 1992), p. 131. [Return to text]



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