Section 1135 emergency waivers were designed as tools for policy-makers to rapidly increase health system capacity during a disaster. Granting regulatory, administrative, or payment-model flexibilities during the covid-19 pandemic, states may be better equipped for an influx of hospitalizations. One month passed before every state adopted a covid-19 waiver and no research investigated why states adopted waivers sooner than others. This study utilizes a Parametric (Gamma) Time-to-Event design to construct a Contextual, Institutional, Political, External, and a combined Integrated model to identify determinants of speedy waiver request. States with Section 1135 precedent in previous disasters submitted requests to CMS more quickly than states without prior experience. In the Integrated Model, four indicators were significantly associated with a shorter time to request: history of a previous waiver (0.7248, p <0.01), state health expenditures (0.9994, p <0.001), a democratic governor (0.6794, p <0.05), and a new 1135 Waiver request in the region (0.8424, p <0.001). Within the U.S. federalist system, states with greater institutional experience and fiscal capacity appeared to act most quickly to expand health system flexibility during the peak of the pandemics uncertainty. Such state variation in ability to respond rapidly to an emergency may confound attempts for equity in this pandemic and beyond.
On January 31, 2020, HHS Secretary Azar declared covid-19 a national public health emergency, which was followed by President Trumps March 13th proclamation declaring the covid-19 outbreak a national emergency (Proclamation No. 9994). In tandem, these two executive actions permitted Secretary Azar to invoke the Section 1135 Waiver Authority, immediately granting medical providers across the country blanket regulatory flexibilities (42 U.S.C. 1320b5). That day, Florida became the first state to initiate additional regulatory flexibilities through an 1135 waiver request (CMS 2020). By April 16, all fifty-one states had submitted a request for specific flexibilities (Medicaid 2020).
While the HHS Secretary can permit blanket waivers over the affected regions, once the Section 1135 Waiver authority has been invoked, states in the designated emergency area can begin initiating state-specific flexibility and capacity requests (CMS 2017). In recent decades, especially with the passage of the Patient Protection and Affordable Care Act (PPACA) which further empowered state waiver institutions (2010), governors and agency directors have been largely responsible for requesting waivers (Thompson, 2013). Though state legislatures have codified statutes which either expedite or hinder a governors ability to act unilaterally, most state legislatures passively allow the executive branch sole authority to request 1135 waivers, leaving governors and agency directors to exercise authority (Hinton, 2019; NCSL 2017).
Emergencies pose an immediate threat to health so it can be safely assumed that, all else equal, a more rapidly requested waiver will be more effective. For the covid-19 emergency, thirty-four days separate the first and last waiver request (CMS 2020). But what caused some states to request a waiver sooner than others? Was this variation a function of covid-19 outcomes? Or, were other state-specific factors contributing to the timing of a request? Previous studies suggest that financial capacity and politics significantly influence the utilization of current waivers (Nattinger, 2016; Nattinger & Kaskie, 2017). Yet, no study has systematically investigated the determinents of emergency waiver adoption.
While likely uncorrelated with the states covid-19 situation, this analysis hypothesizes that Section 1135 waiver precedent from previous emergencies is a major determinant of the timing of a covid-19 waiver request. Along with previous 1135 Waiver experience, this analysis tests if the timing of covid-19 waiver requests are associated with contextual (supply and demand), institutional, political, or external factors. For example, were states with higher proportion of people susceptible to covid-19 hospitalizations more likely quickly demand an increase in hospital capacity? Or, were 1135 Waiver decisions driven by state supply of hospitals? Additionally, after controlling for contextual factors how do state agency, legislative, and executive capacity influence 1135 Waiver time to adoption? And what role, if any, does state ideology play in the realm of emergency waiver negotiations?
Covid-19 has reminded policy-makers that national disasters do not impact states uniformly. Given that 1135 Waivers were designed to provide states flexibility to meet their contextually specific needs, ideally emergency waiver activity during covid-19 will be determined by each states need during the first month of the pandemic. If, however, factors unrelated to need are driving 1135 Waiver timing, then without further action existing disparities could be intensified as a result of underlying differences between the states.
This study utilizes a Time-to-Event analytical design to identify significant determinants influencing the adoption of a states 1135 Waiver request. These study designs have traditionally been used by public health researchers to model survival (Lee & Go, 1997). More generally, any event which is a function of the length of time from onset can be incorporated into a Time-to-Event analysis (Schober & Vetter, 2018). In primary model, the event of interest is a state requesting a Section 1135 Waiver, while the time between disaster proclamation and state request date is the dependent random variable. The primary independent (binary) variable is whether a state has previously requested Section 1135 Medicaid flexibilities during previous emergencies.
Time-to-event policy analyses can be modelled with a multitude of approaches, each allowing for different levels of interpretability and complexity. To enhance the robustness of this study, three different approaches are used: Kaplan-Meier, Cox Proportional Hazard, and Parametric (Gamma).
The Kaplan-Meier analysis, considered the most general, is a non-parametric model which evaluates the time to survival between two distinct groups (Dudley 2016). As a non-parametric model, the Kaplan-Meier estimate will not be sensitive to the underlying distribution of a states time to request. This Kaplan-Meier model compares the timing to a covid-19 waiver request between states with and without 1135 waiver precedent from previous emergencies. However, this Kaplan Meier estimate cannot control for any other covariates influencing a states timing to request (Rich 2010).
To include additional variables which could potentially identify factors influencing a states timing to request, two other approaches are used: A Cox Proportional Hazard Function and Parametric Model. A Cox Proportional Hazards analysis estimates the associated risk of requesting a waiver at any given time (conditional on not having already requested a waiver). Conversely, the parametric model estimates the effect of each variable on the length of time to waiver request. Along with interpretability, this parametric model holds other benefits over the Kaplan-Meier and Cox methods. Typically, parametric models may not be favored as they require additional assumptions related to the selected distribution (Abadi 2012; Siannis 2005). However, a Generalized Gamma incorporates multiple distributions and provides greatest flexibility under minimal assumptions (Cox 2007; Cox & Matheson, 2014; Matheson 2017). Another benefit to the parametric model is the inclusion of robust standard errors, which can account for potential heteroskedasticity in the model (Yau, 2001; Gutierrez, 2002). Following a framework developed by previous time-to-event studies, the Gamma analysis fit a Contextual, Institutional, Political, External, and a combined Integrated model (Berry, 1990; Nelson, 2007; Eaton, 2013). As a sensitivity analysis, Cox model estimates will be reported, along with a test of the assumption that risks do not differentially vary over time for each model.
The data for each states Section 1135 Waiver request date were obtained from CMS correspondence with state Medicaid Directors. Previous 1135 Waiver activity were obtained by a systematic process 1) identifying previous public health emergencies for all states (DHHS, 2020), 2) identifying which public health emergencies led to an invocation of Section 1135 Waiver authority (DHHS 2020), 3) reviewing archival correspondence (CMS 2020; PHE 2019; ASTHO 2010) and federal government reports (81 FR 63859).
Following guidance from previous policy determinants research (Imhof & Kaskie, 2008; Nattinger, 2016; Nattinger & Kaskie, 2017), this studys conceptual framework motivates the inclusion of state indicators related to the supply and demand of covid-19 care (contextual factors); administrative, executive, and legislative capacity to respond to a pandemic (institutional factors); and state ideology (political factors). Additionally, this study includes state and regional indicators to conceptualize external factors which may have influenced when and how a state requested a Section 1135 Waiver. State demand for covid-19 response was operationalized as the percentage of the population over age 65, percentage of the population with multiple co-morbidities, and the percentage of the population covered by Medicaid insurance (Jordan 2020). Given the intensity of treatment necessary to care for covid-19 patients, state supply factors include hospitals per capita and Intensive Care Unit (ICU) beds per capita (Hancock, 2020; Waldman 2020). State Medicaid agency capacity was operationalized using recent state expenditure data (Medicaid, hospitals, and total healthcare spending) and if the state had a current Section 1115 Medicaid Waiver (Jordan 2020; (Hinton 2019). Legislative and Executive Capacity were operationalized with salary and staff expenditure data, while the Executive model also included Line Item Veto and additional public health emergency authority (Jordan 2020; Perkins 2019). State ideology included the current Governors political affiliation, the percentage of Democrats in the current state senate, and the estimated percentage of citizens with liberal views (Jordan 2020; NCSL 2019; NGA 2020). Finally, along with the covid-19 cases and deaths at the time of the requested waiver, the external model also included a binary variable indicating if a new 1135 Waivers was requested in the region. Regions were determined by state networks (Olsen 2019).
States with Section 1135 precedent in previous disasters submitted requests to CMS more quickly than states without prior experience, however these differences were only marginally significant (Figure 1). Figure 1 shows that states with at least one previous 1135 Waiver experience requested a covid-19 waiver more quickly (p = 0.1023). Additionally, states with two or more prior 1135 experiences requested a covid-19 waiver more quickly than states with one or fewer previous 1135 waiver experiences (Figure 2, p = 0.0500). In this unadjusted model (Table 1), the Cox Proportional Hazard for states with 1135 precedent indicated a higher likelihood of requesting a covid-19 waiver at any given time (Hazard Ratio 1.5605), however this effect was not significantly different than states without precedent. For the parametric model, however, the time-to-waiver request was (marginally) significantly less for states with previous 1135 Waiver experience (Time Ratio = 0.7522).
As expected, the Full Integrated Model had the best fit (p < 0.0001). Within this integrated model, four indicators were significantly associated with a shorter time to request: history of a previous waiver (0.7248, p <0.01), state health expenditures (0.9994, p <0.001), a democratic governor (0.6794, p <0.05), and a new 1135 Waiver request in the region (0.8424, p <0.001). The only variable with a statistically significant association with longer time-to-request were covid-19 cases (1.0230, p<-.001). Table 2 reports the full estimates from each models effect on time-to-waiver request, as well as the Cox Proportional Hazards results as a sensitivity analysis.
The critical nature of this ongoing disaster warrants persistent attention from policy-makers at all levels of government. While only a segment of the total covid-19 response, Section 1135 Waivers provide a unique opportunity for states to redirect healthcare resources and expand health system capacity. Yet, this research shows that states have taken different approaches even within the Section 1135 Waiver authority. In summary, institutional (1135 Waiver experience and state agency capacity) and external (a new 1135 Waiver in the region) factors are associated with the timing of a state response. These pre-existing differences between states potentially determining the timing of 1135 policy becomes problematic. However, this new evidence should promote continual innovation by state and local policy-makers. As states continue requesting second and third 1135 Waivers for covid-19 (CMS 2020), the public should expect more timely requests.
The covid-19 pandemic has motivated examinations on American Federalism during a public health emergency. These findings continue that discussion.
The framers of the U.S. Constitution, while never explicitly using the term emergency, understood the risks and benefits of instituting centralized authority during times of national emergencies (Hamilton, 1787). Fearing the risk of unchecked presidential authority as a precursor to tyranny, emergency powers were not allocated to the executive branch (Hamilton and Madison 1788). Rather, Article 1, Section 8 of the U.S. Constitution grants Congress the power to declare war, call upon an army in times of war, and maintain an army during times of peace (critical to any legal analysis of modern emergencies was the foresight to extend these powers to situations seemingly unpredictable in 1788, including disasters during times of peace (Madison 1788)). Yet, despite the risks of concentrated emergency power within the Executive branch, the framers of the Constitution understood the value of such power when responding to an emergency in a timely, effective manner; resulting in largely undefined and broadly interpreted executive authority during emergencies (Fisch, 1990). As presidents began to exert their influence through emergency proclamations and executive orders, the federal Judiciary responded with oversight powers to mitigate presidential overreach (i.e.: Ex parte Merryman 1861; Youngstown Sheet & Tube Co. v. Sawyer 1952).
During the twentieth century, the constitutionally prescribed distribution of emergency powers shifted. Nearing the end of World War II, congress passed the Public Health Services Act (42 U.S.C. ch. 6A 201); of which section 319 grants the Health and Human Services (HHS) Secretary authority to declare a national public health emergency (42 U.S.C. 247d). Two subsequent statutes continued the shift of emergency power from Congress to the President: The National Emergency Act of 1976 (50 U.S.C. 1601-51) and the Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1988 (42 U.S.C. 5121-5207). Both acts explicitly delegate authority to declare a national emergency to the President. Finally, when both a public health and national emergency are declared, the HHS Secretary can invoke Section 1135 Waiver Authority and grant regulatory flexibilities to providers and hospitals in the designated emergency areas (42 U.S.C. 1320b5). However, while precedent is limited, just as in the wartime cases against executive overreach, the Judiciary maintains authority to ensure both the President and Secretary act within their delegated emergency powers (PHN v. U.S. 2015).
Contemporary analysis suggests two general approaches to understanding federalism. The first explores the changing power within each branch and level of government; the second explores the propensity for cooperation (Rigby & Haselswerdt, 2013; Weil, 2013) or competition (Shannon & Kee, 1989; Volden, 2005; Weil, 2009) between jurisdictions. The results of this study provide insight for both approaches. Unlike other Medicaid Waivers, which are largely driven by state executives and agency directors (Weissert & Scheller, 2008; Weissert & Weissert, 2017), Section 1135 Waivers place more authority within the federal executive branch. Even after 1135 invocation, which requires two federal actions, the HHS Secretary immediately provides a set of blanket flexibilities for all states, minimizing any subsequent request. State power is also reduced from the bottom-up, as local or municipal governments and health systems have the ability to bypass state authority to request their own waiver. This reduced authority, however, doesnt apply generally to the covid-19 pandemic which has shown massive expansion of state executives role (Cook 2020). Most interesting, however, is the apparent diffusion between states. By adopting concurrent waivers with other states in each region, the 1135 Waiver diffusion fits other cooperative activity necessary for states to pool resources, signaling that Section 1135 Waiver experience and expertise may be a valuable resource to neighboring states.
This is the first study to identify significant determinants of Section 1135 Waivers. If quality is defined by quicker requests, then the quality of emergency waivers during the covid-19 pandemic are largely determined by institutional and external factors. Meanwhile, supply and demand to do not appear to be driving the timing of emergency waiver decisions. These findings should motivate further research investigating the impact of late adoption effects on covid-19 outcomes, but more importantly, inform immediate policy decisions as state policy-makers continue to navigate the ongoing pandemic
42 U.S. Code 247d. (1944) Public health emergencies.
42 U.S.C. 1320b5 Sec. 1135.
42 U.S.C. 5121-5207 (1988) Robert T. Stafford Disaster Relief and Emergency Assistance Act.
50 U.S.C. 1601-51. (1976) The National Emergency Act.
81 FR 63859. (2016). Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Abadi, A., Amanpour, F., Bajdik, C., & Yavari, P. (2012). Breast Cancer Survival Analysis: Applying the Generalized Gamma Distribution under Different Conditions of the Proportional Hazards and Accelerated Failure Time Assumptions. International Journal of Preventive Medicine, 3(9), 644651.
Association of State and Territorial Health Officials (ASTHO) (2010). ASSESSING POLICY BARRIERS TO EFFECTIVE PUBLIC HEALTH RESPONSE IN THE H1N1 INFLUENZA PANDEMIC. Report to CDC.
Azar, A. (2020) Determination that a Public Health Emergency Exists (COVID-19) U.S. Department of Health and Human Services. https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx
Berry, F. S., & Berry, W. D. (1990). State Lottery Adoptions as Policy Innovations: An Event History Analysis. The American Political Science Review, 84(2), 395415. JSTOR. https://doi.org/10.2307/1963526
Centers for Medicare and Medicaid Services (CMS) (2017). 1135 Waivers. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/1135-Waivers
Centers for Medicare and Medicaid Services (CMS) (2020). CMS Approves First State Request for 1135 Medicaid Waiver in Florida. https://www.cms.gov/newsroom/press-releases/cms-approves-first-state-request-1135-medicaid-waiver-florida
Cook, Nancy & Diamond, Dan. (2020). A Darwinian approach to federalism: States confront new reality under Trump. Politico.
Cox, C., Chu, H., Schneider, M. F., & Muoz, A. (2007). Parametric survival analysis and taxonomy of hazard functions for the generalized gamma distribution. Statistics in Medicine, 26(23), 43524374. https://doi.org/10.1002/sim.2836
Cox, C., & Matheson, M. (2014). A Comparison of the Generalized Gamma and Exponentiated Weibull Distributions. Statistics in Medicine, 33(21), 37723780. https://doi.org/10.1002/sim.6159
Dudley, W. N., Wickham, R., & Coombs, N. (2016). An Introduction to Survival Statistics: Kaplan-Meier Analysis. Journal of the Advanced Practitioner in Oncology, 7(1), 91100.
Eaton, L. J. (2013). Policy Adoption by State Governments: An Event History Analysis of Factors Influencing States to Enact Inpatient Health Care Transparency Laws. http://diginole.lib.fsu.edu/islandora/object/fsu%3A183706/
Ex parte Merryman (1861), 17 F. Cas. 144, 1861 U.S. App. LEXIS 380, 9 Am. Law Reg. 524, 1 Taney 246, 24 Law Rep. 78, 3 W.L. Monthly 461
Exec. Order No. 13648, 78 Fed. Reg. 129 (July 5, 2013).
Gutierrez, R. G. (2002). Parametric Frailty and Shared Frailty Survival Models. The Stata Journal, 2(1), 2244. https://doi.org/10.1177/1536867X0200200102
Hamilton, A. (1787). The Federalist No. 23. Yale Law School. Lilian Goldman Law Library (2008).
Hamilton, A., Madison, J. (1788). The Federalist No. 51. Yale Law School. Lilian Goldman Law Library (2008).
Hancock, F. S., Elizabeth Lucas, Jordan Rau, Liz Szabo, Jay. (2020, March 20). Millions Of Older Americans Live In Counties With No ICU Beds As Pandemic Intensifies. Kaiser Health News. https://khn.org/news/as-coronavirus-spreads-widely-millions-of-older-americans-live-in-counties-with-no-icu-beds/
Hinton, E., Antonisse, L., Feb 12, C. H. P., & 2019. (2019, February 12). Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers. The Henry J. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers/
Imhof, S. L., & Kaskie, B. (2008). Promoting a Good Death: Determinants of Pain-Management Policies in the United States. Journal of Health Politics, Policy and Law, 33(5), 907941. https://doi.org/10.1215/03616878-2008-024
Jordan, Marty P. and Grossmann, Matt. 2020. The Correlates of State Policy Project v.2.2. East Lansing, MI: Institute for Public Policy and Social Research (IPPSR).
Lee, E. T., & Go, O. T. (1997). Survival Analysis in Public Health Research. Annual Review of Public Health, 18(1), 105134. https://doi.org/10.1146/annurev.publhealth.18.1.105
Madison, J. (1788). The Federalist No. 41. Yale Law School. Lilian Goldman Law Library (2008).
Matheson, M., Muoz, A., & Cox, C. (2017). Describing the Flexibility of the Generalized Gamma and Related Distributions. Journal of Statistical Distributions and Applications, 4(1), 15. https://doi.org/10.1186/s40488-017-0072-5
National Conference of State Legislatures (NCSL), as of November 22, 2019. Post-Election 2019 State & Legislative Partisan Composition. https://www.ncsl.org/Portals/1/Documents/Elections/Legis_Control_2019_Post-Election%20Nov%2022nd.pdf
National Conference of State Legislatures (NCSL) (2017). Understanding Medicaid Section 1115 Waivers: A Primer for State Legislators. https://www.ncsl.org/Portals/1/Documents/Health/Medicaid_Waivers_State_31797.pdf
National Governors Association (NGA) (2020). Governor Political Affiliation. https://www.nga.org/wp-content/uploads/2019/07/Governors-Roster.pdf
Nattinger, M. C. (2016). Examining the formation of Medicaid elderly 1915(c) waivers. Theses and Dissertations. https://doi.org/10.17077/etd.nebcf36o
Nattinger, M. C., & Kaskie, B. (2017). Determinants of the Rigor of State Protection Policies for Persons With Dementia in Assisted Living. Journal of Aging & Social Policy, 29(2), 123142. https://doi.org/10.1080/08959420.2016.1236324
Nelson, B. S. (2007). Innovation diffusion: An event history analysis of states adoption of the 1915(c) waiver for people living with HIV /AIDS [Ph.D., University of Maryland, Baltimore County]. https://search.proquest.com/docview/304758706/abstract/6FD968701A394A7CPQ/1
New Orleans Reg'l Physician Hosp. Org., Inc. (PHN) v. United States, 122 Fed. Cl. 807 (2015)
Perkins, Heather. (2019). Book of the States. Council of State Governments.
Proclamation No. 9994, 85 Federal Register 15337 (March 13, 2020).
Public Health Emergency (2019). Public Health Emergency Declarations, All Items.
RICH, J. T., NEELY, J. G., PANIELLO, R. C., VOELKER, C. C. J., NUSSENBAUM, B., & WANG, E. W. (2010). A PRACTICAL GUIDE TO UNDERSTANDING KAPLAN-MEIER CURVES. Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery, 143(3), 331336. https://doi.org/10.1016/j.otohns.2010.05.007
Rigby, E., & Haselswerdt, J. (2013). Hybrid Federalism, Partisan Politics, and Early Implementation of State Health Insurance Exchanges. Publius: The Journal of Federalism, 43(3), 368391. https://doi.org/10.1093/publius/pjt012
Schober, P., & Vetter, T. R. (2018). Survival Analysis and Interpretation of Time-to-Event Data: The Tortoise and the Hare. Anesthesia & Analgesia, 127(3), 792798. https://doi.org/10.1213/ANE.0000000000003653
Shannon, J., & Kee, J. E. (1989). The Rise of Competitive Federalism. Public Budgeting & Finance, 9(4), 520. https://doi.org/10.1111/1540-5850.00836
Siannis, F., Copas, J., & Lu, G. (2005). Sensitivity analysis for informative censoring in parametric survival models. Biostatistics, 6(1), 7791. https://doi.org/10.1093/biostatistics/kxh019
Thompson, F. J. (2013). The Rise of Executive Federalism: Implications for the Picket Fence and IGM. The American Review of Public Administration, 43(1), 325. https://doi.org/10.1177/0275074012461561
U.S. Const. art. I, 8.
U.S. Department of Health and Human Services (DHHS) (2020). 1135 Waiver. Legal Authorizes. Office of the Assistant Secretary for Preparedness and Response.
U.S. Department of Health and Human Services (DHHS) (2020b). 1135 Waiver. Legal Authorizes. Office of the Assistant Secretary for Preparedness and Response. https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx
Volden, C. (2005). Intergovernmental Political Competition in American Federalism. American Journal of Political Science, 49(2), 327342. https://doi.org/10.1111/j.0092-5853.2005.00126.x
Waldman, A., Shaw, A., Ngu, A., & Campbell, S. (2020). Are Hospitals Near Me Ready for Coronavirus? Here Are Nine Different Scenarios. Harvard T.H. Chan School of Public Health. https://projects.propublica.org/graphics/covid-hospitals
Weil, A. (2009). A New Approach To The State-Federal Relationship In Health. Health Affairs, 28(Supplement 1), w188w193. https://doi.org/10.1377/hlthaff.28.2.w188
Weil, A. (2013). Promoting Cooperative Federalism Through State Shared Savings. Health Affairs, 32(8), 14931500. https://doi.org/10.1377/hlthaff.2013.0334
Weissert, C. S., & Scheller, D. (2008). Learning from the States? Federalism and National Health Policy. Public Administration Review, 68(s1), S162S174. https://doi.org/10.1111/j.1540-6210.2008.00986.x
Weissert, C. S., & Weissert, W. G. (2017). Medicaid waivers and negotiated federalism in the US: Is there relevance to other federal systems? Journal of Health Services Research & Policy, 22(4), 261264. https://doi.org/10.1177/1355819617702175
Yau, K. K. W. (2001). Multilevel Models for Survival Analysis with Random Effects. Biometrics, 57(1), 96102. https://doi.org/10.1111/j.0006-341X.2001.00096.x
Youngstown Sheet & Tube Co. v. Sawyer, 343 U.S. 579 (1952)
Click here to access the appendix.
42 U.S. Code 247d. (1944) Public health emergencies.
42 U.S.C. 1320b5 Sec. 1135.
42 U.S.C. 5121-5207 (1988) Robert T. Stafford Disaster Relief and Emergency Assistance Act.
50 U.S.C. 1601-51. (1976) The National Emergency Act.
81 FR 63859. (2016). Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Abadi, A., Amanpour, F., Bajdik, C., & Yavari, P. (2012). Breast Cancer Survival Analysis: Applying the Generalized Gamma Distribution under Different Conditions of the Proportional Hazards and Accelerated Failure Time Assumptions. International Journal of Preventive Medicine, 3(9), 644651.
Association of State and Territorial Health Officials (ASTHO) (2010). ASSESSING POLICY BARRIERS TO EFFECTIVE PUBLIC HEALTH RESPONSE IN THE H1N1 INFLUENZA PANDEMIC. Report to CDC.
Azar, A. (2020) Determination that a Public Health Emergency Exists (COVID-19) U.S. Department of Health and Human Services. https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx
Berry, F. S., & Berry, W. D. (1990). State Lottery Adoptions as Policy Innovations: An Event History Analysis. The American Political Science Review, 84(2), 395415. JSTOR. https://doi.org/10.2307/1963526
Centers for Medicare and Medicaid Services (CMS) (2017). 1135 Waivers. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/1135-Waivers
Centers for Medicare and Medicaid Services (CMS) (2020). CMS Approves First State Request for 1135 Medicaid Waiver in Florida. https://www.cms.gov/newsroom/press-releases/cms-approves-first-state-request-1135-medicaid-waiver-florida
Cook, Nancy & Diamond, Dan. (2020). A Darwinian approach to federalism: States confront new reality under Trump. Politico.
Cox, C., Chu, H., Schneider, M. F., & Muoz, A. (2007). Parametric survival analysis and taxonomy of hazard functions for the generalized gamma distribution. Statistics in Medicine, 26(23), 43524374. https://doi.org/10.1002/sim.2836
Cox, C., & Matheson, M. (2014). A Comparison of the Generalized Gamma and Exponentiated Weibull Distributions. Statistics in Medicine, 33(21), 37723780. https://doi.org/10.1002/sim.6159
Dudley, W. N., Wickham, R., & Coombs, N. (2016). An Introduction to Survival Statistics: Kaplan-Meier Analysis. Journal of the Advanced Practitioner in Oncology, 7(1), 91100.
Eaton, L. J. (2013). Policy Adoption by State Governments: An Event History Analysis of Factors Influencing States to Enact Inpatient Health Care Transparency Laws. http://diginole.lib.fsu.edu/islandora/object/fsu%3A183706/
Ex parte Merryman (1861), 17 F. Cas. 144, 1861 U.S. App. LEXIS 380, 9 Am. Law Reg. 524, 1 Taney 246, 24 Law Rep. 78, 3 W.L. Monthly 461
Exec. Order No. 13648, 78 Fed. Reg. 129 (July 5, 2013).
Gutierrez, R. G. (2002). Parametric Frailty and Shared Frailty Survival Models. The Stata Journal, 2(1), 2244. https://doi.org/10.1177/1536867X0200200102
Hamilton, A. (1787). The Federalist No. 23. Yale Law School. Lilian Goldman Law Library (2008).
Hamilton, A., Madison, J. (1788). The Federalist No. 51. Yale Law School. Lilian Goldman Law Library (2008).
Hancock, F. S., Elizabeth Lucas, Jordan Rau, Liz Szabo, Jay. (2020, March 20). Millions Of Older Americans Live In Counties With No ICU Beds As Pandemic Intensifies. Kaiser Health News. https://khn.org/news/as-coronavirus-spreads-widely-millions-of-older-americans-live-in-counties-with-no-icu-beds/
Hinton, E., Antonisse, L., Feb 12, C. H. P., & 2019. (2019, February 12). Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers. The Henry J. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers/
More:
- 2024 Lok Sabha Elections: Need to pitch for Federalism and Special Status for Goa - Herald Goa - April 6th, 2024 [April 6th, 2024]
- 1999 constitution and the quest for true federalism - Nigerian Observer - April 6th, 2024 [April 6th, 2024]
- Federalism is not Apartheid The Mail & Guardian - Mail and Guardian - April 6th, 2024 [April 6th, 2024]
- Modi has delivered confrontational federalism: Congress | Siddaramaiah highlights 'injustices to K'taka | Inshorts - Inshorts - April 6th, 2024 [April 6th, 2024]
- Lebanese Pro-Federalism Activist Alfred Riachi: Prior To October 7, The Standard Of Living In Gaza Was Pretty ... - Middle East Media Research... - February 22nd, 2024 [February 22nd, 2024]
- The Potential Impact of 'Disease X' on Federalism in the U.S. - Medriva - February 22nd, 2024 [February 22nd, 2024]
- 'People's Charter' Puts Federalism at The Heart of Myanmar's Democratic Future - The Irrawaddy - February 22nd, 2024 [February 22nd, 2024]
- Siddaramaiah vs Modi: The 'cess-y' mess in fiscal federalism - Deccan Herald - February 22nd, 2024 [February 22nd, 2024]
- Ideas Of India: Devendra Fadnavis To Take A Deep Dive Into Role Of Collaborative Federalism In Nation-Building - ABP Live - February 22nd, 2024 [February 22nd, 2024]
- Potential of federalism should be realized: PM Dahal - The Himalayan Times - February 22nd, 2024 [February 22nd, 2024]
- Sensible education policy needed - The Kathmandu Post - October 9th, 2023 [October 9th, 2023]
- Both cooperative federalism and competitive federalism have their ... - Insights IAS - August 18th, 2023 [August 18th, 2023]
- Federalism to poll promises: South India CMs bring up host of local ... - South First - August 18th, 2023 [August 18th, 2023]
- Justice Mitchell (Alabama): "The New Bar Exam Puts DEI Over ... - Reason - May 20th, 2023 [May 20th, 2023]
- Season of instability - The Kathmandu Post - May 20th, 2023 [May 20th, 2023]
- Trump Indictment Tests Congress's Role in State Investigations - Bloomberg Law - May 20th, 2023 [May 20th, 2023]
- Big Business' New Plan Would Create Fifty New Immigration Policies - Federation for American Immigration Reform - May 20th, 2023 [May 20th, 2023]
- Senator decries move to block bill loosening Wisconsin abortion law - Milwaukee Journal Sentinel - May 20th, 2023 [May 20th, 2023]
- "Illegally buying time": Congress leader Abhishek Singhvi chastises ... - ANI News - May 20th, 2023 [May 20th, 2023]
- Baby Ninth Amendments Part IV: All the Rights but Not ALL the Rights - Reason - May 20th, 2023 [May 20th, 2023]
- Amid the Fight for Myanmar, Federalism Rises from the Grass Roots - United States Institute of Peace - May 18th, 2023 [May 18th, 2023]
- Lesson from Karnataka respect states and India's federalism - Deccan Herald - May 18th, 2023 [May 18th, 2023]
- Dr. Paul Nolette named director of Les Aspin Center for Government ... - Marquette Today - May 18th, 2023 [May 18th, 2023]
- Sen. Cramer Welcomes ND Witnesses, Discusses Water ... - Kevin Cramer - May 18th, 2023 [May 18th, 2023]
- Utilities, Transmission, and the Grid: An Interview with Ari Peskoe - Brown Political Review - May 18th, 2023 [May 18th, 2023]
- Six months after elections, provincial governments are still incomplete - The Kathmandu Post - May 18th, 2023 [May 18th, 2023]
- NON-FICTION: WHY FEDERALISM ENDURES IN PAKISTAN ... - DAWN.com - May 6th, 2023 [May 6th, 2023]
- Justice Scalia's Unpublished Dissent in Kelo v. City of New London - Reason - May 6th, 2023 [May 6th, 2023]
- Citizens, civil society hold the ruling party, BJP to account ... - SabrangIndia - May 6th, 2023 [May 6th, 2023]
- ED Proposes Title IX Athletics Rule Requiring Participation Based ... - The Federalist Society - May 6th, 2023 [May 6th, 2023]
- The Mysterious Case of the Imposition of Article 355 in Manipur - The Wire - May 6th, 2023 [May 6th, 2023]
- Non-BJP State Governments Not Exercising Accountability, Allowing ... - Daily Excelsior - May 6th, 2023 [May 6th, 2023]
- Two years of Stalin government in Tamil Nadu: Two steps forward - Times of India - May 6th, 2023 [May 6th, 2023]
- What is the issue of gubernatorial inaction in the legislative process ... - Insights IAS - April 29th, 2023 [April 29th, 2023]
- World Bank Approves $100 Million to Strengthen Nepal's Healthcare ... - ReliefWeb - April 29th, 2023 [April 29th, 2023]
- Canada's federal transfer payment system badly needs a tune-up - The Conversation - April 29th, 2023 [April 29th, 2023]
- 50 years of basic structure doctrine | Only safeguard against majoritarian govt: Sr Advocate Ramachandran - The Indian Express - April 29th, 2023 [April 29th, 2023]
- Federalism - Definition, Examples, Cases, processes - Legal Dictionary - February 20th, 2023 [February 20th, 2023]
- What is federalism? | State Policy Network - February 5th, 2023 [February 5th, 2023]
- UPSC Key- January 19, 2023: Learn about Annual Status of Education Report, Federalism and State Legislatures - The Indian Express - January 19th, 2023 [January 19th, 2023]
- Advantages and Disadvantages of Federalism American Government - January 6th, 2023 [January 6th, 2023]
- fiscal federalism | public finance | Britannica - December 26th, 2022 [December 26th, 2022]
- About ALEC - American Legislative Exchange Council - December 12th, 2022 [December 12th, 2022]
- Canadian federalism - Wikipedia - November 23rd, 2022 [November 23rd, 2022]
- U.P. bags top honours at PMAY-U Awards 2021 - The Hindu - November 23rd, 2022 [November 23rd, 2022]
- Political Line sc views on conversions rajiv convicts and federalism and more - The Hindu - November 21st, 2022 [November 21st, 2022]
- Byron Williams: The court is poised to rewrite federalism - Winston-Salem Journal - October 17th, 2022 [October 17th, 2022]
- Why Hindi may set the tone for 2024 - Deccan Herald - October 17th, 2022 [October 17th, 2022]
- A Myanmar roadmap: Charting the path to federal democracy - International IDEA - October 17th, 2022 [October 17th, 2022]
- Next generation of reforms should focus on reducing cost of doing business - Economic Times - October 17th, 2022 [October 17th, 2022]
- Nigeria And The Intrigues Of Insecurity -By Kene Obiezu - Opinion Nigeria - October 17th, 2022 [October 17th, 2022]
- Trudeau's aggressive federalism may leave Ottawa weaker than before - The Globe and Mail - October 15th, 2022 [October 15th, 2022]
- What is Federalism? | CSF - October 15th, 2022 [October 15th, 2022]
- Kerala Against Hindi Imposition; Terms Recommendations Attack on Federalism and Diversity of Nation - NewsClick - October 15th, 2022 [October 15th, 2022]
- 2023: Well Vote for Candidate Committed to Federalism, Diversity, Says UPU - THISDAY Newspapers - October 15th, 2022 [October 15th, 2022]
- Attorney General Knudsen fights Biden administration rule requiring states to reach net-zero highway emissions - Montana Department of Justice - October 15th, 2022 [October 15th, 2022]
- How Scotland can learn from Quebec's third way on constitution - HeraldScotland - October 15th, 2022 [October 15th, 2022]
- Federalism and Why Presidents Fail - THISDAY Newspapers - September 22nd, 2022 [September 22nd, 2022]
- Vedanta and the missing spirit of federalism - The New Indian Express - September 22nd, 2022 [September 22nd, 2022]
- Federalism Most Suited Idea For India In View Of Its Diversity, Centralising Whole Things Will Lead To... - Live Law - Indian Legal News - September 22nd, 2022 [September 22nd, 2022]
- Urging the Use of One Federal Decision Rule to Speed Up Bipartisan Infrastructure Law Projects - Kevin Cramer - September 22nd, 2022 [September 22nd, 2022]
- Constitution Day 2022: Celebrating the right to govern ourselves - Yellowhammer News - September 22nd, 2022 [September 22nd, 2022]
- From Augusta Constitution Day: What does it mean to you? - Press Herald - September 22nd, 2022 [September 22nd, 2022]
- Explained | The office of the Governor: its origins, powers, and controversies - The Hindu - September 22nd, 2022 [September 22nd, 2022]
- Geography Professional Speaker Series kicks off with alumnus from Ohio EPA on Sept. 23 - Ohio University - September 22nd, 2022 [September 22nd, 2022]
- Vector-borne diseases trouble Nepal every year as there is not a single entomologist - Online Khabar (English) - September 22nd, 2022 [September 22nd, 2022]
- The Gujarat factor in the development project - Hindustan Times - September 22nd, 2022 [September 22nd, 2022]
- The downslide in federal relations - The Indian Express - September 22nd, 2022 [September 22nd, 2022]
- Competition between states to attract investment will boost Indias economy - Moneycontrol - September 22nd, 2022 [September 22nd, 2022]
- For state of the nation, look at states of the nation: Niti Aayogs new chief says it will help states learn - Times of India - September 22nd, 2022 [September 22nd, 2022]
- Letters to the Editor: Queen injected vitality, vigour into lives of many - The Kingston Whig-Standard - September 22nd, 2022 [September 22nd, 2022]
- Climate action that runs on cooperative federalism - The Hindu - September 15th, 2022 [September 15th, 2022]
- The spirit of federalism - The News International - September 15th, 2022 [September 15th, 2022]
- Javier Perez Sandoval Receives the 2022 William Anderson Award - - Political Science Now - September 15th, 2022 [September 15th, 2022]
- A new Constitutional Convention is a very bad idea | Opinion - Knoxville News Sentinel - September 15th, 2022 [September 15th, 2022]
- Rodney Hero Receives the 2022 Barbara Sinclair Lecture Award - - Political Science Now - September 15th, 2022 [September 15th, 2022]
- Department of the Interior, Fish and Wildlife Service: Migratory Bird Hunting; 20222023 Seasons for Certain Migratory Game Birds - Government... - September 15th, 2022 [September 15th, 2022]
- Increasing Threat To Federalism From Centrally Sponsored Schemes- Need To Form A Federal Front - Countercurrents.org - September 3rd, 2022 [September 3rd, 2022]
- Breakenridge: Supporting federalism is the only way Alberta can be a partner in LNG exports - Calgary Herald - September 3rd, 2022 [September 3rd, 2022]
- Two tools for tracking the American Rescue Plans local and national impacts - Brookings Institution - September 3rd, 2022 [September 3rd, 2022]