Driven by the need to reform unsustainable entitlement programs, policymakers today are looking to the successful example of welfare reform—specifically, to its block grants to states. To inform this discussion, a new Mercatus Center at George Mason University study by Daniel Sutter reviews arguments in the debate over block grants versus matching grants for joint federal-state programs, examines the effects of shifting control of welfare programs to the states, and considers how the lessons from welfare reform can inform the current debate about Medicaid block grants.
In the wake of a 2012 Supreme Court ruling, states face complex decisions concerning whether to expand Medicaid coverage to the full extent envisioned in the Affordable Care Act (ACA, commonly referred to as Obamacare). With the federal government no longer able to coerce expansion, states must base their decisions on value judgments that incorporate each state’s unique budgetary circumstances, the needs of its uninsured population, and the incentives established by interactions among the ACA’s provisions.
Federal and state governments are under increasing pressure to limit Medicaid spending without negative health consequences. We examine a unique policy effort in West Virginia aimed at reducing spending and improving health through personal responsibility and preventive care. These efforts show promise for reducing emergency-room (ER) visits among those who chose the personal-responsibility plan but had the unintended consequence, at least in the short run, of increasing visits for those who defaulted into the plan with reduced benefits.
This paper examines the fiscal health of the states, focusing on two worrisome characteristics: an understatement of unfunded pension liabilities and ever-increasing expenditures, driven primarily by health care costs.
This working paper finds that the quality and use of analysis for the ACA interim final rules falls well below that of conventional notice-and-comment rulemaking by other agencies, including HHS. The poor quality of analysis in the examined ACA rules is comparable to the quality of analysis that accompanied a series of interim final homeland security regulations issued by the Bush administration following 9/11. This suggests that institutional—rather than partisan—factors explain why the quality of regulatory analysis declines when agencies implement significant presidential priorities on short deadlines.
This working paper demonstrates that the low-quality analysis for the ACA regulations was a predictable result of the way that the administration and Congress chose to manage the regulatory process. Presidential and congressional decisions, in turn, reflected the political incentives both actors faced in 2010. To promote transparency and informed decision-making, additional checks and balances in the regulatory process are needed so politics will not short-circuit analysis.
Federal agencies issued eight major “interim final regulations” in 2010 to quickly implement major provisions of the ACA. This working paper demonstrates that analyses for these regulations were seriously incomplete, often omitting significant benefits, costs, or regulatory alternatives. Analysis of fairness was cursory at best.