1 Politika Analiz Modelleri (Policy Analysis Models) Muammer Cetingok, MSW, PhD College of Social Work Memphis Campus The University of Tennessee, Knoxville, USA Ankara, Turkiye Aralik 2008 Kopyahakki(Copyright) Bu konusmanin hicbir bolumu konusmacinin izni olmaksizin kullanilamaz ve yeniden uretilemez.
2 Giris Sosyal refah alani, egitim kurumlari da dahil olmak uzere, politika analiz cercevelerinin kuramsal ve kavramsal gelistirilmesi ve ogretilmesiyle gorevlidir. Politika analizi, sosyal hizmet alanindaki arastirma/calisma ve uygulamalarin akilci ve gerekli bir yonu olmaktadir. Politika analizi cagdas sosyal refah makro uygulamasinin ayrilamaz bir bolumudur. Sosyal politika bazli hizmet veren sosyal refah orgutlerinin de politika analizi ile ilgilenmeleri dogal bir surectir.
3 Politika analiz modelleri iki bolumde sunulurlar: Nitelikli ( sonuc/urun ve/veya surec uzerine odaklasmis olarak), ve, Nicelikli. On ozet olarak sunlari soyleyebilirz: Sonuc/ urun tabanli/odakli nitelikli modeller, gerektiginde ve zamaninda, politikalarin yeniden tasarimlanmalari ve degistirilmeleri icin butunlesmis ve kapsamli sonuc bilgileri (kiymetlendirme ve degerlendirme) saglarlar.
4 Yine, sonuc/urun tabanli/odakli nitelikli modeller, sosyo-ekonomik sistemler, demokrasi, sosyal adalet, esitlik, insan haklari, tam katilimli (universal), artikli (residual), paylasimli (shared), indirgenmis (devolutionary) sosyal refah, ve evrensel sosyal refah gibi makro egitim ve uygulamasina ozel, temel ve koklesmis kavramlari bizlere tanitirlar.
5 Surec odakli nitelikli modeller, politikalarin nasil uygulandiklarini irdelerler; sonuc tartismalarina girmezler. Politikalarin uygulamalarindaki girisimlerin ve sureclerin, misyon ve amaclarina uygun olup olmadiklarina bakarlar, ve toplanan bilgileri politika degerlendirmesinde kullanirlar. Nicelikli modeller, sayisal degiskenlerin analizlerde kullanilma temeline bagli olarak, politika degerlendirmelerinde kullanilirlar. Hem surec, hem de sonuc odakli olabilirler.
6 Bu modelleri ve icerdikleri kavramlari iyi anlamadan, ne ogrencilerimize politika ogretebiliriz, ne de makro uygulamacilarimizin bilgili / akilli politika kararlari vermelerini ve degerlendirme yapmalarini bekleyebiliriz.
7 Amaclar Bu nedenle, bu konusmanin iki amaci vardir: 1) Politika analizi ve model kavramlarini tanimladiktan sonra, sosyal bilim ve sosyal refah literaturunde halen varolan, seckin bir takim sonuc ve surec odakli nitelikli modelleri ayrintili ve nicelikli modelleri de ozetli tanimak ve incelemek,
8 2) Her turlu politika analiz calismalarinda kullanilmak uzere. cogunlukla sonuc amacli nitelikli modelleri temel alan, ve fakat nicelikli modellerle de entegre edilmis, pragmatik ve bu arada globallesme ve doga cevrecilik kavramlarini da iceren daha cagdas yeni bir model uretmek (inclusion of global and physical environmental impacts of social policy in its analysis)
9 Kuskusuz, analizleri yapabilmenin on sartlari vardir: Analizi yapilacak politikanin ayrintili bir taniminin [(politikanin temelindeki sorun(lar) ve politikanin amaclari ve hedeflerini de iceren bir bicimde) yapilmasi; Sosyal / hukuki metninin onceden ozenli bir bicimde incelenmesi; Politikanin kullanilan modele gore bolumlerine ayrilabilmesi;
10 Kritik dusunceyi iceren, akilci, ve kanita bagli analiz uygulamasi; Ezber (memory), onyargi (prejudiceprejudgment), ve ekolojik yanlisliklar kullanilmamasi (ecological fallacy, ornek: politika toplumu hedef almasina ragmen, kisiler uzerindeki etkilerini incelemek- makro ekonomi hedefleriyle (ulkenin refahi-maliye, para, buyume, vb. )mikro ekonomi hedeflerini (firma ve kisilerin refahi) karistirmak).
11 Ilk amaci yerine getirmek icin: Politika, politika analizi ve model tanimlarini asagidaki gibi yapacagiz (kendi tanimlarimiz) ve daha sonra da modelleri aciklayacagiz: Politika, bir amaca ulasmak icin saptanan yoldur. Politika analizi, bir politikanin basarili olup olmadigini, veya yazildigi bicimde uygulanip uygulanmadigini saptamak icin yapilan calismadir. Politikanin icerigini ogrenmek, ve kanita dayali uygulama prensibini kullanarak veriler toplamak ve bu verileri, analiz modelinin temel kistaslarina gore bolumlere ayirmak, incelemek ve degerlendirmek bu calismanin bolumleridir.
12 Model, secilmis yapilarin (olusumlarin) ve/veya unsurlarin yargilanmalari icin, ya dogal veya kavramsal olarak gelistirilmis ve arzulanan bir bicim, olusma, veya yapidir. [We define model as a naturally and/or conceptually desired shape, configuration or construction by which the entities of relevance are to be judged (our definition)]. Politika analizinde model, genelde kavramsal olarak ulasilmistir; secilmis sosyal, kulturel, ekonomik, ve diger arzu edilen sonuclara yonelik kistaslari iceren bir yapidir. Modelden modele kistaslar degisebilir.
13 Ikinci amaci yerine getirmek icin, modellerin hepsinde varolan musterek kistaslari kesfedip, inceleyecegiz ve biraraya getirme surecinden gecerek, alti basamaktan olusan modelimizi sunacagiz. Simdi, modellerimizin aciklamalarina baslayabiliriz:
14 Modeller Sonuc Bazli Nitelikli Modeller Gil (1970) Kaynak dagitimi (allocation of resources) Haklar dagilimi-esitlik(firsat-sonuc esitligi) (rights allocation-equality(of opportunity-of outcome) Statu dagilimi-layiklik (status allocation)) Haklar-statuler baglantisi (link between rights and status allocation) Gil, D. G. (1970). A systematic approach to social policy analysis. Social Service Review, 44(4),
15 Gilbert and Terrell (2005) Secim temelleri:(foundations of choice) 3 soru? Soru 1) Degerler (Values)? Bireysel degercilik (Individualism) Masraf/etkenlik (cost/effectiveness)-enfazla gereksinimi olanlara ver; Secme ozgurlugu (freedom of choice)-para ver; Dusunce ozgurlugu (freedom of dissent)-demokrasi sagla-insanlarin kendi duzenlemelerine izin ver; Yorel bagimsizlik (local autonomy)-yorel yonetimlere para ver)
16 Toplumsal degercilik (Collectivism) Sosyal etkenlik (social effectiveness)-herkese ver; Social denetim (social control)-para verme;diger provisyonlari ver; Verimlilik (efficiency)-burokratik ve en verimli bicimde hizmet ver; Merkezcilik (centralization)-mali isleri merkezden yonet-ozel amacli, kategorik para sagla) Esitlik (equality), liyakat (equity), ve yeterlik (adequacy) kavramlari da degerler olarak tartisilabilirler.
17 Soru 2) Kuramlar (Theories) (Ornek:fakirlik kurami-bireysel hata; toplumsal hata) Soru 3) Secenekler (Alternatives) (Akla yatkin, varolan, yaratilan politika secenekleri (ornek: para dagitmanin degisik yollari nelerdir?)
18 Secim boyutlari (Dimensions of choice): 4 soru? Soru 1) Dagilimlarin temelleri? (Basis of social allocations) (Universal-Selective? Kim alacak? Her vatandas; secilen vatandas (ornegin: cocuklar); gereksinimi olan vatandas (evsiz); teshis/tani dayanikli dagilim; odenek/tazminat; kanitlanmis ekonomik gereksinim; degisik karisimli temeller) Soru 2) Sosyal tedariklerin cesitleri? (Types of social provisions) (Ne verilecek? Para/kart, kredi (vergi kredisi), kupon, esya/mal, hizmet, firsat/guc/kuvvet, sosyal ve ekonomik kalkinma yararlari, diger tedarikler)
19 Soru 3) Hizmet verme duzeni? (Service Delivery System) Butunsel-Universal-herkesi iceren/ artiksalresidual(secmeli); Kamusal (public); Ozel (private) (kar amaci gutmeyen/kar amacli) Kamu-ozel karisimi hizmet duzeni; Kamu on planda / Kamu destekleyici rolde
20 Hizmet orgutlesmeleri Merkezi yonetim-yerel yonetim(centralizeddecentralized) Vatandas katilimi-burokratik control(citizen participation-bureaucratic control) Daginik-koordinasyonlu (fragmented-coordinated) Sureksiz (kopuk)-surekli (discontinuity-continuous) Ulasilabilir-Ulasilamaz (Accessible-Inaccessible) Kime sorumlu? Kamu-ozel (Accountable to whom? Public-private)
21 Soru 4) Maliye/ fon/ para destegi ve nasil verildigi? (Modes of finance) Kamu politikasina dayali / ozel politikaya bagli Kamu parasi-vergiler / Kategorik odeme (bir formule bagli birim birim odeme); blok para verilerek tum odeme; genel gelir dagilimi (bir formule gore genel dagitim) Kamu-federal ve lokal yonetim paylasimi Kamu-ozel sektor paylasimi;
22 ozel sektor (kamu destegi, oduller; rekabetler; bagislar; hizmet karsiligi odemeler; hizmet birimlerine gore odemeler; ozel para ile verilen hizmetler; Yukaridakilerden olusan, degisik karma modeller ); Gilbert, N, & Terrell, P. (2005). Dimensions of social welfare policy. Boston: Pearson. Mullins, K. (1980). Class notes.
23 Verimlilik (efficiency) (Yapilan harcamanin karsiligi alindi mi? Bir bakima girdi-cikti analizini ornek alabiliriz.) Kelley (1975) Yeterlilik (adequacy) gereksinim giderildi mi? Etkenlik (effectiveness)(yardimalan kisinin ozkimligi-kendine guven olumlu olarak degisti mi? ve kendi kendine karar verme hakki (Var mi? verildi mi?
24 Meenaghan & Washington (1980) Ahlak (ethics): dini (deontolojik-dogmatik) faydacilik (utiliteryan, faydali-etkenli tezlerine dayali ahlak) Goreceli ahlak (relativistik; duruma bagli (situational); kulturden gelen; gidise uygun (pragmatik yaklasim) Adillik (esitlikte adillik; liyakatte adillik) Yeterlilik (aciklandi.) Esitlik (aciklandi) Finansman dagilimi-maliye (aciklandi) Hizmetlerin goturulme yontem ve orgutleri (aciklandi)
25 Moroney (1981) Ozgurluk (liberty); temel degerleri kullanarak secim yapabilme Esitlik (equality), Dayanisma (fraternity) butunlesmeentegrasyon
26 Prigmore & Atherton (1979) Kultur (culture) ve degerler (values):kultur ve degerlere yatkinlik ve uygunluk Nufuz ve karar verme (influence and decision-making) siyasi yatkinlik (political acceptability) ve mesruluk (legality) Akla yatkinlik (rationality) Tutar (harcama)/cikar (faydalar) analizi (costs/benefits )
27 Popple & Leighninger (2001) Politikanin genel tanimi ve icerigi / incelenmesi Tarihce: (Yeni veya eski-(siralamali/yigilimli/ incremental) Toplumsal Analiz (sorun; etkilenen nufus: Kuramlar / Degerler/Amaclar Ekonomik Analiz / degerlendirme (makro and mikro ekonomik etkiler/ masraf/yarar analizi Siyasi/Politik Analiz / degerlendirmeler: Katilimcilar;destekleyicilerin ve karsitlarin gucleri; Politakadan yararlananlarin katilimlari; mesruluk; rasyonal/inkremental/catismali karar verme surecleri; siyasetin rolu) Politikanin degistirilmesi icin guncel oneriler
28 Surec Bazli Nitelikli Modeller (Process-Based Qualitative Analytic Models) Eylem Sistemi Modeli (The Action System model): Ilk girisim / baslatmak; desteklemek; himaye edenleri saptamak; mesrulastirmak (kanunlastirma sureci); yurutmeye koymak (5N-1K sorulari) (SOWER, C. et al. (1957). Community involvement: The webs of formal and informal ties that make for action. Glencoe, IL.: The Free Press. WARREN. R.L. (1977). Social change and human purpose: Toward understanding and action. Chicago. IL.: Rand McNally. ) Rekabet Eden Problemlerin Tanimi modeli (The competing problems definition model) Ozel (kisisel veya bir gruba ozel) sorunlari kamu sorunlari bicimine donusturmek ve bu sorunlari kamu gundemine almak; anlasmaya ve uzlasmaya gitmek ve kanun gecirmek (ROSS, R. AND STAINES, G.L. (1972). The politics of analyzing social problems. Social Problems, 20, )
29 Siralamali ve yigilimli / eklemeli model (Sequential/incremental model): Partizan analistlerin rollerini incelemek; temsilci politika yapicilarini tanimak; daha onceden konulmus kurallari kullanmak; uzlasmak (taviz verme) kuralini bilmek LINDBLOOM, C. (1959). The science of muddling through. Public Administration Review, 19, Destekleme modeli (The leverage model): Bireysel aktorlarin kisisel yeterlilikleri invcelemek, politika sorununun, baglantili / ilgili sosyal sistemler icindeki onemini / belirgenligini saptamak; eylem sistemine ayrilmis cesitli kaynaklari saptamak (zaman, insangucu, iletisim, para / finans, teknik kapasite), (GERGEN, K.J. (1968).Assessing the leverage points in the process of policy formation. In R. Bauer,& K. Gergen, (Eds.), The study of policy formation (pp ). New York: The Free Press.
30 Kuramsal bazli nitelikli analitik cerceveler (Model olarak kullanilabilirler) Kurumculuk ve kamu politikasi Grup kurami: grup dengesi olarak politika Elit (seckinler) kurami Akilcilik kurami Eklemecilik kurami Oyun kurami Sistem (duzen) kurami Dye (1965). Understanding Public Policy,
31 Nicelikli politika analizi modelleri Girdi-Islendi(Surec)-Cikti (input-throughputoutput) Farklilik Esitlikleri (Difference equations): Belirgin sureler icinde degiskenlerde olusan degisiklikler Sira Duzeni (Queuing ): Arz-talep dengesi; hizmete harcanan zaman; siralama ozellikleri (sorunun dogasi, vb.) Luse, F.D. (1982). OUTPST: Education/Simulations for the Human Services. Park Forest, Illinois. Bilgisayarda Benzetme (Computer simulations) Jaffe, E.D. (1979). Computers in child placement planning. Social Work, 24(5), Lawrence, B. et al. (1981). A decision support system to increase equity, Administration in Social Work, 5(3/4), Luse, F.D. (1980). Use of computer simulation in social welfare management. Administration in Social Work, 4(3),
32 Markov Zinciri (Markov Chain): Kullanicilarin veya hizmet asamalarinin sistem icinde akislarini izleme Cikar (fayda)/tutar(harcama) (Benefit/cost) Duz(dizili) Programlama (Linear Programming): Kisintili miktarlarda olan kaynaklarin programa/projeye dagitimi;programi /projeyi tamamlamak icin gereken en az kaynak veya tutar / harcama Karar Analizi (Decision analysis): Stratejik kararlari gerektiren program gelismeleri / mihenk taslari/asamalari (STOKEY, E. AND ZECKHOUSER, R. (1978). A primer for policy analysis. New York: Norton.
33 Cetingok (2008) Hatirlayacaginiz uzre, bizim modelimiz cogunlukla sonuc amacli nitelikli modelleri temel alan, ve fakat nicelikli modellerle de entegre edilmis, pragmatik ve bu arada globallesme ve doga (physical) cevrecilik kavramlarini da iceren daha cagdas yeni bir model olarak dusunulmustu. Dolayisiyle, asagidaki modelin gunumuz sosyal mantik/ dusuncelerine ve gerceklerine daha uygun olacagini oneriyoruz ve modeli alti asamada yapilandiriyoruz:
34 Globallesme ve dogal cevrecilik temelleri ve iceriginde bir politika analizi modeli: Cagdas bir yaklasim 1) Sosyal adalet ve sayisal/oransal esitlik; liyakat sorunlari (social justice and numeric and proportional equality/equity concerns; 2) Katilim (firsat ve sonus esitlikleri) ve sosyal entegrasyon sorunlari (participation (equality of opportunities and outcomes) and social integration concerns; 3) Yeterlilik, etkenlik, verimlilik sorunlari (adequacy, effectiveness/efficiency questions;
35 4) Politikadan yararlananlar ve politikanin getirdigi yararlar (determination of beneficiary targets and natures of policy benefits; and 5) Orgutlesme ve hizmet verme/goturme sistemleri, finansman sorunlari 5) organization and delivery systems and financing of policy benefits. 6) Politikanin getirdigi evrensel ve cevresel etkiler ve degisiklikler [Not: Jansson, Bruce S. (2003). Becoming an effective policy advocate: From policy practice to social justice. (p. 40). Belmont, Ca.: Thomson; and, Flynn, J.P. (1985). Social Agency Policy: analysis and presentation for Community Practice. (pp. 76, 97, 115, 132). Chicago: Nelson_Hall. cevrenin politikaya etkileri ve sosyal hizmette cevresel yaklasim gibi kavram dizilerini kullanmislardir. Iatridis, D. (1994). Social Policy: Institutional Context od Social Development and Human Services. (p. 138). Pacidic Grove, Ca.: Brooks/Cole natural environment kavramini liberal econominin cevre uzerindeki etkilerini anlatirken kullanmistir. Bunlara ragmen, sosyal politikanin dogaya da etkilerini iceren bir politika analiz modeli
36 Sonuc Tum politika analitik modeller, icinde bulundugumuz zamanlarin bilgi, becerilerinden kaynaklanan, ve sosyal, kulturel, ekonomik, siyasal, evrensel, ve cevresel cerceveler temellerinde ve iceriklerinde gelistirilmis yapilardir. Konusmamiza konu olan tum modellerin, modelimizde dahil olmak uzere, yine yukaridaki temellere ve iceriklere dayali olarak gelecekte hem inkremental hem de koklu degismelere ugramalari kacinilmazdir. Dolayisiyla, bugun bu modelleri kullanmamizla birlikte yeni gelismelere de acik olmamiz ve gelecek analizlerimizde degisimler ve eklemeler yapmamiz dogaldir. Tesekkur ederim.
37 References Dye, T.R. (1965). Understanding Public Policy. (4 th Ed.). Englewood Cliffs, N.J.: Prentice-Hall. Gergen, K.J. (1968).Assessing the leverage points in the process of policy formation. In R. Bauer,& K. Gergen, (Eds.), The study of policy formation (pp ). New York: The Free Press. Gil, D. G. (1970). A systematic approach to social policy analysis. Social Service Review, 44(4), Gilbert, N, & Terrell, P. (2005). Dimensions of social welfare policy. Boston: Pearson. Iatridis, D. (1994). Social Policy: Institutional Context od Social Development and Human Services. (p. 138). Pacidic Grove, Ca.: Brooks/Cole Jansson, Bruce S. (2003). Becoming an effective policy advocate: From policy practice to social justice. (p. 40). Belmont, Ca.: Thomson. Flynn, J.P. (1985). Social Agency Policy: analysis and presentation for Community Practice. (pp. 76, 97, 115, 132). Chicago: Nelson_Hall. Kelley, J.B. (1975). Educating social workers for a changing society: Social policy. Journal of Education for Social Work, 14(2), Lindbloom, C. (1959). The science of muddling through. Public Administration Review, 19, Meenaghan, T.M. & Washington, R.O. (1980). Social policy and social welfare: Structure and applications. New York: The Free Press.
38 Moroney, R.M. (1981). Policy analysis within a value theoretical framework. In R. Haskins, & J.J. Gallagher (Eds.), Models for policy analysis of social policy: An introduction (pp ). Norwood, N.J.:Ablex Pub. Corp. Mullins, K. (1980). Class notes. Prigmore, C.S. & and Atherton, C.R. (1979). Social welfare policy: Analysis and formulation. Lexington, Mass.: D.C. Heath. Popple, P.R. & Leighninger, L. (2001). The Policy-Based Profession: An Introduction to Social Welfare Policy analysis for Social Workers. Boston: Allyn and Bacon. Ross, R. & Staines, G.L. (1972). The politics of analyzing social problems. Social Problems, 20, ) Sower, C. et al. (1957). Community involvement: The webs of formal and informal ties that make for action. Glencoe, IL.: The Free Press. Stokey, E. & Zeckhouser, R. (1978). A primer for policy analysis. New York: Norton. Warren. R.L. (1977). Social change and human purpose: Toward understanding and action. Chicago. IL.: Rand McNally. )
39 Good health is important to everyone. If you can't afford to pay for medical care right now, Medicaid can make it possible for you to get the care that you need so that you can get healthy and stay healthy. Medicaid is available only to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services. ("Medicaid At-A-Glance 2005" may be downloaded from the bottom of the page.)
40 Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services. Read more about your state Medicaid program. (See Related Links inside CMS at the bottom of the page.) Many groups of people are covered by Medicaid. Even within these groups, though, certain requirements must be met. These may include your age, whether you are pregnant, disabled, blind, or aged; your income and resources (like bank accounts, real property, or other items that can be sold for cash); and whether you are a U.S. citizen or a lawfully admitted immigrant. The rules for counting your income and resources vary from state to state and from group to group.
41 There are special rules for those who live in nursing homes and for disabled children living at home. Your child may be eligible for coverage if he or she is a U.S. citizen or a lawfully admitted immigrant, even if you are not (however, there is a 5-year limit that applies to lawful permanent residents). Eligibility for children is based on the child's status, not the parent's. Also, if someone else's child lives with you, the child may be eligible even if you are not because your income and resources will not count for the child. In general, you should apply for Medicaid if your income is low and you match one of the descriptions of the Eligibility Groups. (Even if you are not sure whether you qualify, if you or someone in your family needs health care, you should apply for Medicaid and have a qualified caseworker in your state evaluate your situation.)
42 Screening Tools To help you see if you may be eligible for a variety of governmental programs, you may access the GovBenefits and BenefitsCheckUp websites. (See related links inside CMS at the bottom of the page.) When Eligibility Starts Coverage may start retroactive to any or all of the 3 months prior to application, if the individual would have been eligible during the retroactive period. Coverage generally stops at the end of the month in which a person's circumstances change. Most States have additional "State-only" programs to provide medical assistance for specified poor persons who do not qualify for the Medicaid program. No Federal funds are provided for State-only programs.
43 What is Not Covered Medicaid does not provide medical assistance for all poor persons. Even under the broadest provisions of the Federal statute (except for emergency services for certain persons), the Medicaid program does not provide health care services, even for very poor persons, unless they are in one of the designated eligibility groups. Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds. As noted earlier, categorically needy persons who are eligible for Medicaid may or may not also receive cash assistance from the TANF program or from the SSI program. Medically needy persons who would be categorically eligible except for income or assets may become eligible for Medicaid solely because of excessive medical expenses.
44 geographic proximity. Thus, a person who is eligible for Medicaid in one State may not be eligible in another State, and the services provided by one State may differ considerably in amount, duration, or scope from services provided in a similar or neighboring State. In addition, State legislatures may change Medicaid eligibility, services, and/or reimbursement during the year. States generally have broad discretion in determining which groups their Medicaid programs will cover and the financial criteria for Medicaid eligibility. To be eligible for Federal funds, however, States are required to provide Medicaid coverage for certain individuals who receive federally assisted income-maintenance payments, as well as for related groups not receiving cash payments. In addition to their Medicaid programs, most States have additional "State-only" programs to provide medical assistance for specified poor persons who do not qualify for Medicaid. Federal funds are not provided for State-only programs. The following enumerates the mandatory Medicaid "categorically needy" eligibility groups for which Federal matching funds are provided: Basis of Eligibility and Maintenance Assistance Status Medicaid does not provide medical assistance for all poor persons. Under the broadest provisions of the Federal statute, Medicaid does not provide health care services even for very poor persons unless they are in one of the groups designated below. Low income is only one test for Medicaid eligibility for those within these groups; their resources also are tested against threshold levels (as determined by each State within Federal guidelines).
45 Individuals who would be eligible if institutionalized, but who are receiving care under home and community-based services (HCBS) waivers. Certain aged, blind, or disabled adults who have incomes above those requiring mandatory coverage, but below the FPL. Recipients of State supplementary income payments. Certain working-and-disabled persons with family income less than 250 percent of the FPL who would qualify for SSI if they did not work. TB-infected persons who would be financially eligible for Medicaid at the SSI income level if they were within a Medicaid-covered category (however, coverage is limited to TB-related ambulatory services and TB drugs). Certain uninsured or low-income women who are screened for breast or cervical cancer through a program administered by the Centers for Disease Control. The Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Public Law ) provides these women with medical assistance and follow-up diagnostic services through Medicaid. "Optional targeted low-income children" included within the State Children's Health Insurance Program (SCHIP) established by the Balanced Budget Act (BBA) of 1997 (Public Law ). "Medically needy" persons (described below). The medically needy (MN) option allows States to extend Medicaid eligibility to additional persons. These persons would be eligible for Medicaid under one of the mandatory or optional groups, except that their income and/or resources are above the eligibility level set by their State. Persons may qualify immediately or may "spend down" by incurring medical expenses that reduce their income to or below their
46 disabled children, who lost SSI as a result of the restrictive changes; however, their eligibility for Medicaid was reinstituted by Public Law , the BBA. In addition, welfare reform repealed the open-ended Federal entitlement program known as Aid to Families with Dependent Children (AFDC) and replaced it with Temporary Assistance for Needy Families (TANF), which provides States with grants to be spent on time-limited cash assistance. TANF generally limits a family's lifetime cash welfare benefits to a maximum of 5 years and permits States to impose a wide range of other requirements as well--in particular, those related to employment. However, the impact on Medicaid eligibility is not expected to be significant. Under welfare reform, persons who would have been eligible for AFDC under the AFDC requirements in effect on July 16, 1996 generally will still be eligible for Medicaid. Although most persons covered by TANF will receive Medicaid, it is not required by law. Title XXIof the Social Security Act, known as the State Children's Health Insurance Program (SCHIP), is a new program initiated by the BBA. In addition to allowing States to craft or expand an existing State insurance program, SCHIP provides more Federal funds for States to expand Medicaid eligibility to include a greater number of children who are currently uninsured. With certain exceptions, these are low-income children who would not qualify for Medicaid based on the plan that was in effect on April 15, Funds from SCHIP also may be used to provide medical assistance to children during a presumptive eligibility period for Medicaid. This is one of several options from which States
47 funds are to be received. A State's Medicaid program must offer medical assistance for certain basic services to most categorically needy populations. These services generally include the following: Inpatient hospital services. Outpatient hospital services. Prenatal care. Vaccines for children. Physician services. Nursing facility services for persons aged 21 or older. Family planning services and supplies. Rural health clinic services. Home health care for persons eligible for skilled-nursing services. Laboratory and x-ray services. Pediatric and family nurse practitioner services. Nurse-midwife services. Federally qualified health-center (FQHC) services, and ambulatory services of an FQHC that would be available in other settings. Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21. States may also receive Federal matching funds to provide certain optional services. Following are the most common of the thirty-four currently approved optional Medicaid services: Diagnostic services. Clinic services. Intermediate care facilities for the mentally retarded (ICFs/MR). Prescribed drugs and prosthetic devices. Optometrist services and eyeglasses.
48 of physician visits covered. Two restrictions apply: (1) limits must result in a sufficient level of services to reasonably achieve the purpose of the benefits; and (2) limits on benefits may not discriminate among beneficiaries based on medical diagnosis or condition. In general, States are required to provide comparable amounts, duration, and scope of services to all categorically needy and categorically related eligible persons. There are two important exceptions: (1) Medically necessary health care services that are identified under the EPSDT program for eligible children, and that are within the scope of mandatory or optional services under Federal law, must be covered even if those services are not included as part of the covered services in that State's Plan; and (2) States may request "waivers" to pay for otherwise uncovered home and community-based services (HCBS) for Medicaid-eligible persons who might otherwise be institutionalized. As long as the services are cost effective, States have few limitations on the services that may be covered under these waivers (except that, other than as a part of respite care, States may not provide room and board for the beneficiaries). With certain exceptions, a State's Medicaid program must allow beneficiaries to have some informed choices among participating providers of health care and to receive quality care that is appropriate and timely. Payment for Medicaid Services Medicaid operates as a vendor payment program. States may pay health care providers directly on a fee-for-service basis, or States may pay for Medicaid services through various prepayment arrangements, such as health maintenance organizations (HMOs). Within federally imposed upper
49 institutional care. In addition, all Medicaid beneficiaries must be exempt from copayments for emergency services and family planning services. The Federal Government pays a share of the medical assistance expenditures under each State's Medicaid program. That share, known as the Federal Medical Assistance Percentage (FMAP), is determined annually by a formula that compares the State's average per capita income level with the national income average. States with a higher per capita income level are reimbursed a smaller share of their costs. By law, the FMAP cannot be lower than 50 percent or higher than 83 percent. In fiscal year (FY) 2004, the FMAPs varied from 50 percent in twelve States to percent in Mississippi, and averaged 60.2 percent overall. The BBA also permanently raised the FMAP for the District of Columbia from 50 percent to 70 percent and raised the FMAP for Alaska from 50 percent to 59.8 percent through The BIPA of 2000 further adjusted Alaska's FMAP to a higher level for FY The Jobs and Growth Tax Relief Reconciliation Act of 2003 (Public Law ), in order to bring about State fiscal relief in the current troubled economy, has made three temporary modifications to the States' FMAP calculation: (1) the FMAP for the last two quarters of 2003 will equal the greater of the current law FMAPs for 2002 or 2003; (2) the FMAP for the first three quarters of 2004 will equal the greater of the current law FMAPs for 2003 or 2004; and (3) for the last two quarters of 2003 and first three quarters of 2004, the newly calculated (under 1 and 2 above) FMAP will increase by 2.95 percentage points. The Federal Government pays States a higher share for children covered through the SCHIP
50 The Federal Government also reimburses States for 100 percent of the cost of services provided through facilities of the Indian Health Service, provides financial help to the twelve States that furnish the highest number of emergency services to undocumented aliens, and shares in each State's expenditures for the administration of the Medicaid program. Most administrative costs are matched at 50 percent, although higher percentages are paid for certain activities and functions, such as development of mechanized claims processing systems. Except for the SCHIP program, the Qualifying Individuals (QI) program (described later), and DSH payments, Federal payments to States for medical assistance have no set limit (cap). Rather, the Federal Government matches (at FMAP rates) State expenditures for the mandatory services, as well as for the optional services that the individual State decides to cover for eligible beneficiaries, and matches (at the appropriate administrative rate) all necessary and proper administrative costs. The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (as incorporated into Public Law , the appropriations bill for the District of Columbia for FY 2000) increased the amount that certain States and the territories can spend on DSH and SCHIP payments, respectively. The BIPA set upper payment limits for inpatient and outpatient services provided by certain types of facilities.
51 assistance program. Legislative changes also focused on increased access, better quality of care, specific benefits, enhanced outreach programs, and fewer limits on services. In most years since its inception, Medicaid has had very rapid growth in expenditures. This rapid growth has been due primarily to the following factors: The increase in size of the Medicaid-covered populations as a result of Federal mandates, population growth, and economic recessions. The expanded coverage and utilization of services. The DSH payment program, coupled with its inappropriate use to increase Federal payments to States. The increase in the number of very old and disabled persons requiring extensive acute and/or long-term health care and various related services. The results of technological advances to keep a greater number of very low-birth-weight babies and other critically ill or severely injured persons alive and in need of continued extensive and very costly care. The increase in drug costs and the availability of new expensive drugs. The increase in payment rates to providers of health care services, when compared to general inflation. As with all health insurance programs, most Medicaid beneficiaries incur relatively small average expenditures per person each year, and a relatively small proportion incurs very large costs. Moreover, the average cost varies substantially by type of beneficiary. National data for 2001, for example, indicate that Medicaid payments for services for 23.3 million children, who constitute 50 percent of all Medicaid beneficiaries, average about $1,305 per child (a relatively small average expenditure per person). Similarly,
52 cost of care for persons using nursing facility or home health services in National data for 2001 show that Medicaid payments for nursing facility services (excluding ICFs/MR) totaled $37.2 billion for more than 1.7 million beneficiaries of these services--an average expenditure of $21,890 per nursing home beneficiary. The national data also show that Medicaid payments for home health services totaled $3.5 billion for more than 1.0 million beneficiaries--an average expenditure of $3,475 per home health care beneficiary. With the percentage of our population who are elderly or disabled increasing faster than that of the younger groups, the need for long-term care is expected to increase. Another significant development in Medicaid is the growth in managed care as an alternative service delivery concept different from the traditional fee-for-service system. Under managed care systems, HMOs, prepaid health plans (PHPs), or comparable entities agree to provide a specific set of services to Medicaid enrollees, usually in return for a predetermined periodic payment per enrollee. Managed care programs seek to enhance access to quality care in a costeffective manner. Waivers may provide the States with greater flexibility in the design and implementation of their Medicaid managed care programs. Waiver authority under sections 1915(b) and 1115 of the Social Security Act is an important part of the Medicaid program. Section 1915(b) waivers allow States to develop innovative health care delivery or reimbursement systems. Section 1115 waivers allow Statewide health care reform experimental demonstrations to cover uninsured populations and to test new delivery systems without increasing costs. Finally, the BBA provided States a new option to use managed care. The
53 More than 46.0 million persons received health care services through the Medicaid program in FY 2001 (the last year for which beneficiary data are available). In FY 2003, total outlays for the Medicaid program (Federal and State) were $278.3 billion, including direct payment to providers of $197.3 billion, payments for various premiums (for HMOs, Medicare, etc.) of $52.1 billion, payments to disproportionate share hospitals of $12.9 billion, and administrative costs of $16.0 billion. Outlays under the SCHIP program in FY 2003 were $6.1 billion. With no changes to either program, expenditures under Medicaid and SCHIP are projected to reach $445 billion and $7.5 billion, respectively, by FY The Medicaid-Medicare Relationship Medicare beneficiaries who have low incomes and limited resources may also receive help from the Medicaid program. For such persons who are eligible for full Medicaid coverage, the Medicare health care coverage is supplemented by services that are available under their State's Medicaid program, according to eligibility category. These additional services may include, for example, nursing facility care beyond the 100-day limit covered by Medicare, prescription drugs, eyeglasses, and hearing aids. For persons enrolled in both programs, any services that are covered by Medicare are paid for by the Medicare program before any payments are made by the Medicaid program, since Medicaid is always the "payer of last resort."
54 (QMBs) and Specified Low-Income Medicare Beneficiaries (SLMBs) are the best-known categories and the largest in numbers. QMBs are those Medicare beneficiaries who have resources at or below twice the standard allowed under the SSI program, and incomes at or below 100 percent of the FPL. For QMBs, Medicaid pays the Hospital Insurance (HI, or Part A) and Supplementary Medical Insurance (SMI) Part B premiums and the Medicare coinsurance and deductibles, subject to limits that States may impose on payment rates. SLMBs are Medicare beneficiaries with resources like the QMBs, but with incomes that are higher, though still less than 120 percent of the FPL. For SLMBs, the Medicaid program pays only the Part B premiums. A third category of Medicare beneficiaries who may receive help consists of disabled-and-working individuals. According to the Medicare law, disabled-and-working individuals who previously qualified for Medicare because of disability, but who lost entitlement because of their return to work (despite the disability), are allowed to purchase Medicare Part A and Part B coverage. If these persons have incomes below 200 percent of the FPL but do not meet any other Medicaid assistance category, they may qualify to have Medicaid pay their Part A premiums as Qualified Disabled and Working Individuals (QDWIs). For Medicare beneficiaries with incomes that are above 120 percent and less than 175 percent of the FPL, the BBA establishes a capped allocation to States, for each of the 5 years beginning January 1998, for payment of all or some of the Medicare Part B premiums. These beneficiaries are known as Qualifying Individuals (QIs). Unlike QMBs and SLMBs, who may be eligible for other Medicaid benefits in
55 The Centers for Medicare & Medicaid Services (CMS) estimates that Medicaid currently provides some level of supplemental health coverage for about 6.5 million Medicare beneficiaries. Starting January 2006, the new Medicare prescription drug benefit will provide drug coverage for Medicare beneficiaries, including those who also receive coverage from Medicaid. In addition, individuals eligible for both Medicare and Medicaid will also receive the low-income subsidy for both the Medicare drug plan premium and assistance with cost sharing for prescriptions. Medicaid will no longer provide drug benefits for Medicare beneficiaries. Since the Medicare drug benefit and low-income subsidy will replace a portion of State Medicaid expenditures for drugs, States would see a reduction in Medicaid expenditures. To offset this reduction, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law ) requires each State to make a monthly payment to Medicare representing a percentage of the projected reduction. For 2006 this payment is 90 percent of the projected 2006 reduction in State spending. After 2006 the percentage decreases by 1-2/3 percent per year to 75 percent for 2014 and later. NOTE: Medicaid data are based on the projections of the Mid-Session Review of the President's Fiscal Year 2005 Budget and are consistent with data received from the States on the Forms CMS-2082, MSIS, CMS-37, and CMS- 64.