Assessing the New Federalism is a multiyear Urban Institute project designed to analyze the devolution of responsibility for social programs from the federal government to the states, focusing primarily on health care, income security, employment and training programs, and social services. Alan Weil is the project director. Researchers monitor program changes and fiscal developments. In collaboration with Child Trends, the project studies changes in family well-being. The project aims to provide timely, nonpartisan information to inform public debate and to help state and local decisionmakers carry out their new responsibilities more effectively.

Key components of the project include a household survey, studies of policies in 13 states, and a database with information on all states and the District of Columbia, available at the Urban Institute's Web site. This paper is one in a series of discussion papers analyzing information from these and other sources.

The project has received funding from the Annie E. Casey Foundation, the W.K. Kellogg Foundation, the Robert Wood Johnson Foundation, the Henry J. Kaiser Family Foundation, the Ford Foundation, the John D. and Catherine T. MacArthur Foundation, the Charles Stewart Mott Foundation, the David and Lucile Packard Foundation, the McKnight Foundation, the Commonwealth Fund, the Stuart Foundation, the Weingart Foundation, the Fund for New Jersey, the Lynde and Harry Bradley Foundation, the Joyce Foundation, and the Rockerfeller Foundation.

The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.

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Contents

Snapshots of America's Families: Variations in Health Care across States
The National Survey of America's Families
Results

Adults and Children
Children's Health Insurance
Adult Health Insurance
Health Status, Usual Source, and Confidence

Discussion
Notes
References
About the Authors

Snapshots of America's Families: Variations in Health Care across States

The May/June 1998 issue of Health Affairs contained a series of articles describing the Urban Institute's Assessing the New Federalism (ANF) study and summarizing health policy case studies from 13 states (Kondratas, Weil, and Goldstein 1998). Assessing the New Federalism is a multiyear Urban Institute research project to analyze the devolution of responsibility for social programs from the federal government to the states, focusing primarily on health care, income security, job training, and social services. The case studies examined issues such as eligibility for public insurance, the effects of welfare reform, Medicaid managed care, Medicaid disproportionate share hospital (DSH) payments, long-term care for the elderly, and public health. The case studies found extensive variation in states' policies toward low-income families that tended to be a function of each state's political culture, values, and fiscal circumstances (Holahan, Wiener, and Wallin 1998).

In this paper, we present preliminary findings from the 1997 National Survey of America's Families (NSAF)—the household survey component of ANF—related to insurance coverage, health status, and access to care. The survey contains nationally representative data from almost 45,000 families throughout the entire distribution of income. NSAF is unique because (1) it contains information on a broad range of economic, social, and health care topics not otherwise available in a single survey; (2) the sample was designed to allow for state-specific estimates from the 13 case study states; and (3) low-income families (below 200 percent of the federal poverty level) were oversampled. The low-income oversample is particularly critical because the policies that ANF is studying have their greatest effect within this large and potentially vulnerable group. The results discussed here focus on the differences across the 13 case study states for children and adults in low-income families.

These data, and the ANF project overall, should be viewed as a means of understanding the ongoing process of devolution that has been shifting more responsibility for designing social programs from the federal government to the states. Medicaid has always been a federal/state partnership. Within a set of federal rules, states have had flexibility in establishing criteria for eligibility, benefits, and provider payment and, with waivers, have moved to widespread adoption of managed care. States have also taken the initiative in developing DSH programs that play a major role in funding safety net hospitals. When Congress enacted a new program to provide coverage to more low-income children—the Children's Health Insurance Program—it gave the states even more of a role in setting eligibility rules and establishing the program's structure.

The results presented here serve as a starting point within the ANF study for analyzing how state policies may be affecting the well-being of low-income families.¹ We start by examining differences in current insurance coverage, health status, and usual source of care between adults and children at the national level. This overview documents the outcomes of policies within Medicaid, CHIP, and other state programs that have expanded coverage for children to a greater extent than they have for adults. We then report on state variation in these indicators for all children and adults and for low-income children and adults. The basic structure of the cross-state analysis is similar to earlier work by Cantor, Long, and Marquis (1998) using the 1993 Robert Wood Johnson Foundation Family Health Insurance Survey.

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Notes

1. Future rounds of NSAF are planned and will allow us to try to explain how outcomes are changing under various policy regimes.

The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.

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