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A critical look at state-dominated health care

Medicaid and the Limits of State Health Reform

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Michael S. Sparer

"A wonderful combination of rich detail and penetrating insight on diverse political cultures. Essential reading for all who grapple with the return of political power to the states."
Professor Sylvia A. Law, School of Law, New York University

With the defeat of national health reform, many liberals have looked to the states as the source of health policy innovation. At the same time, many in the new Republican majority and several governors also support increased state control. In contrast, Michael S. Sparer convincingly argues that states by themselves can neither satisfy the liberal hope for universal coverage nor the conservative hope for cost containment. He also points to two critical drawbacks to a state-dominated health care system: the variation in coverage among states and the intergovernmental tension that would inevitably accompany such a change.

Supporting his arguments, Sparer analyzes the contradictions in operations and policies between the New York and California Medicaid programs. For instance, why does New York spend an average of $7,286 on its Medicaid beneficiaries and California an average of $2,801? The answer, the author suggests, is rooted in bureaucratic politics. California officials enjoy significant bureaucratic autonomy, while the system in New York is fragmented, decentralized, and interest-group dominated. The book supports this conclusion by exploring nursing home and home care policy, hospital care policy, and managed care policy in the two states. Sparer's dissection of the consequences of state-based reform make a persuasive case for national health insurance.

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Excerpt

Read an excerpt from Chapter 1 (pdf).

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Reviews

"Sparer's insightful account...throws invaluable light on the sources of variation among states and the meaning of variation for the disadvantaged citizens Medicaid serves.... His book is a major contribution to the literature on the politics of health care policy."
Lawrence D. Brown, School of Public Health, Columbia University

"Michael Sparer offers a much needed balance to the one-sided, state-oriented 'devolution-revolution' approach to public policy....[The book] is well organized and tightly written."
The American Political Science Review

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Contents

Acknowledgments
1. The State Role in Health Care Reform: Why do We Care?
2. Congress Considers Health Reform
3. Explaining Medicaid Variation
4. The Medicaid Programs in New York and California
5. Paying for the Institutionalized Aged: Lessons from Nursing Home Policy
6. Alternatives to Institutionalization: Lessons from Home Care Policy
7. Reducing the Cost of Hospital Care: Lessons from New York and California
8. Moving Medicaid Clients into Managed Care
9. States and the U.S. Health Care System
Notes
Index

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About the Author(s)

Michael S. Sparer is Assistant Professor of Health Policy in the School of Public Health at Columbia University.

Subject Categories

Health and Health Policy
Political Science and Public Policy

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