Federalism, intergovernmental relations and implementation: A broad examination of the politics of Medicaid disenrollment

Variation in the Medicaid program has frequently been studied across states, and considered a product of political, fiscal and administrative factors. Few studies have considered variation in Medicaid as a product of federal bureaucratic behavior. This study examines federal variation, and uses federalism, intergovernmental relations and public policy lenses to compare two cases where classes of recipients were being disenrolled from Medicaid, in apparent conflict with federal regulations. In one case, when individuals moved from county-to-county and became disenrolled in Medicaid, the federal bureaucrats used most of the implementation tools at their disposal to try to bring states back into compliance by simply transferring cases. In another, when inmates were being disenrolled from Medicaid upon incarceration, and not being re-enrolled upon release, federal bureaucrats used few of the same tools to establish corrective action. This research focused on answering the question of why the variation in federal activity took place, and how the bargaining and negotiation that the federal principals did engage in impacted the implementation behavior of the state agents.;The findings indicate that federal variation across these cases was primarily related to three factors: (1) conflict and complexity of the regulations across audit, fiscal and programmatic lines; (2) lack of administrative resources to properly monitor and administer the program at the federal level; and (3) the political priorities of the ruling regimes. Perhaps the most interesting findings were that after more than a decade of negotiating with New York State, the federal principals were not able to get New York Medicaid officials to change their policy implementations. It was only when advocates and local bureaucrats became involved, and expanded the scope of conflict to the legislature and the courts, that the State Office of Health Insurance Programs initiated the changes necessary to ensure continuous enrollment.