Block grants and state discretion: A study of the implementation of the partnership for health act in three states

This article examines the use of federal funds provided to state health departments under a grant consolidation of eight previously categorical health programs in Michigan, Pennsylvania, and Alabama in a comparative context. The primary question addressed is why the three states chose to describe their allocations of funds within the total health department budget differently, and what political, administrative, and bureaucratic factors explained the differences. Although certain factors were found to be at work in all states (e.g. each had an incentive to concentrate the reported use of federal funds to simplify federal audits) these factors combined with circumstances unique to each state to produce different expenditure patterns. After examining the experience of three states, general hypotheses are developed. For example, it is hypothesized that more volatile changes in allocations will result from grant consolidations in policy areas which do not address basic service needs. Finally the decision-making process with respect to block grant funds is characterized as one in which a small group of professionals determined allocations autonomously with relatively little input from interest groups or other actors within state government; nevertheless, the external political and administrative environment severely limited the possibilities of realistic choice in each of the three states studied.I wish to thank the National Center for Health Services Research which supported this study under grant HS 01495. I am indebted to the state health department officials in Alabama, Michigan, and Pennsylvania who made this research possible. I would also like to thank Leonard Robins, Janet Shikles, William Schmalzreid, Bruce Vladeck, John Kingdon and Robert Baitty for comments on an earlier draft. Of course the views expressed are my own and in no way reflect the positions of the Department of Health and Human Services.     

Variations in appointment delays for physicians' services: Theory and empirical evidence

Waiting times for physician appointments have been used in past studies as a measure of access to, or excess demand pressure on, local ambulatory care systems. This paper offers an alternative view—that short appointment delays are one of several types of amenities produced by physicians in combination with health services. Empirical evidence is presented that illuminates some previously unknown relationships between appointment delays, patient diagnosis, site of care, and family income. A model is developed with the capability of predicting short-run responses to changes in demand for physicians' services. The model and empirical evidence are used as the basis for interpreting recent experience in Canada with its system of national health insurance (NHI) and for predicting potential consequences regarding the production of amenities of NHI in the US.This research has been supported in part by a grant (HS—00825) from the Center for Health Services Research, US Department of Health, Education, and Welfare, to the University of Florida. We are indebted to John B. Wayne and to Paula Sloan for their assistance and to University of Florida colleague Gary Shannon for comments on an earlier draft.     

Citizens' voluntary governing boards: Waiting for the quorum

In complex societies formal power, legitimacy, and responsibility are typically allocated to councils, or governing boards. This is an old strand in American political culture, strengthened by the growth of private not-for-profit organizations and concern for citizens' representation. It is also a growing trend in Great Britain, West Germany, and other modern societies. Such boards are often taken for granted; we think we understand them, hence the value of investigating the obvious. In this essay they are examined with respect to their external and internal relations (or structure), their problems and performance (or processes), and the blurred nature of their authority in an interpenetrated society where public and private interests are inextricably intertwined. Illustrations are derived from the author's research in the governance of labor union locals, municipal governments and reform movements, urban renewal efforts, community mental health centers, and private hospital governing boards.This paper is based in part on research supported by The National Center for Health Services Research, Department of Health and Human Services, U.S. Government Grant No. R01-HS-03238-02.     

Band-aid solutions

She has been a faculty member at Carnegie Mellon University; Director of the Division of Economic and Quantitative Analysis, Office of the Deputy Assistant Secretary for Planning and Evaluation, Department of Health and Human Services; and Director of the Office of Research in the Health Care Financing Administration. She is president of the Foundation for Health Services Research.     

Health and Health Services Access Among Adults With Disabilities Who Receive Federal Housing Assistance

Using newly available U.S. Department of Housing and Urban Development (HUD) administrative data linked with National Health Interview Survey data, this study estimates the prevalence of disability among HUD-assisted adults and examines health disparities for this population. The linked data suggest a much higher prevalence of disability among HUD-assisted adults than previously suggested by HUD administrative data. Controlling for individual characteristics and HUD program type, assisted-housing residents who have disabilities experienced higher rates of self-reported fair or poor health, asthma, diabetes, hypertension, obesity, and cigarette smoking. Adults with disabilities had more frequent use of emergency rooms and increased concerns with affording the necessary health care. HUD-assisted adult residents with disabilities were more likely than residents without disabilities to be connected to the health-care system, having higher rates of insurance coverage and more frequent contact with specialists, general doctors, and mental health-care providers. Policy implications are discussed.     

Explaining a health care paradox

The paradox of a statistically weak linkage between physician density and measures of health based on outcome has recently received much attention because of its importance to health planning policy. It is demonstrated here that the linkage is stronger than indicated by previous studies if the statistical model is more carefully specified. A single case-type is chosen so that the impact of physician services is not filtered out by the aggregation process and a quantitative variable measuring case severity is derived. When statistical techniques are applied to correct for case-risk and for the inherent heteroscedasticity in observed mortality rates across states and time, the positive effect of physician density on health is shown to be statistically highly significant. Thus the apparently paradoxical findings in previous studies may be a result of failing to correct not only for differences in case severity but also for variations in sample errors. Also, even though the magnitude of physician impact is small compared to non-medical variables, an exploratory estimate of the impact of government programs focused on prevention suggests that present allocations between prevention and treatment may approximate optimality.The project upon which this paper is based was performed pursuant to Research Grant HS01036 from the Bureau of Health Services Research and Evaluation, U.S. Department of Health, Education and Welfare. The author wishes to acknowledge the advice and encouragement of Llad Phillips and H. E. Frech.     

Going It Alone or Playing to the Crowd? A Critique of Individual Budgets and the Personalisation of Health Care in the English National Health Service

The introduction of individual budgets into English health care is a recent example of the pervasive drive towards personalisation in welfare sector organisation and delivery. As a heavily centralised and highly bureaucratic institution, the National Health Service (NHS) is an obvious target for personalisation. On the other hand, as a symbol of solidarity and nationhood it retains a powerful place within the collective psyche, such that radical reform might expect to encounter resistance. This paper analyses the assumptions that are inherent in personalisation and raises concerns over its ability to transform health‐care services. At the heart of these concerns is the tension between appeals to tailored service provision and empowerment on the one hand, and promotion of a strong social contract, public trust in institutions, and collective identity on the other. Lessons are drawn for personalisation in other sectors and settings.     

Public policy and health resource distribution

Despite federal health programs of the thirties, the Great Society programs and the establishment of health planning agencies in the sixties, health resources continue to accumulate in wealthier areas. According to a rational decision-making model public resources would be expected therefore to be directed toward those poorer areas with perceived needs. This paper explores the distribution of public and private health resources among towns of Connecticut. Using a rational decision-making model, the distribution of these resources is tested in a series of stepwise regression equations against the socioeconomic and health characteristics of the population. Private allocations of health resources (such as physician distribution) respond to socioeconomic factors while public resources do not show a clear pattern of overcoming the maldistribution effected by private actions. We find little evidence to support the hypothesis that Connecticut's town and state decision makers in health were following a rational model such as is the basis for health planning. Some other more complex model, such as a bureaucratic politics model, would explain better public policy decisions in health resource allocation.Research for this paper was carried out under Department of Health, Education, and Welfare Grant #5-R01-HS-00900. We wish to thank Berton Freedman for assistance with computer programming, and our former Yale Health Policy Project colleagues, George A. Silver, James Warner Bjorkman, and Christa Altenstetter for comments on an earlier draft. This earlier paper entitled Socio-Economic Indicators, Health Resources and Health Status: A Statistical Analysis and its Policy Implications was presented to the Statistics Section, American Public Health Association Meetings, November 16–20, 1975, Chicago, Illinois.     

The relocation of released mental hospital patients into residential communities

The mental health patient release programs have been proceeding more rapidly than informed judgment could possibly warrant. Public sector mental health care, whether centralized in state hospitals or deconcentrated within residential communities, falls considerably below the standards and practices of private sector care. The accelerated release of former patients has strained the potential for therapeutic community placement. The massive reassignment of patients has been prompted by the goals of: providing for the civic and therapeutic rights of patients; providing knowledgeable and effective treatment; implementing cost savings; and integrating in-patients within a more aware and accepting inclusive society. The structural elements of the assignment process can be examined within the context of a reassignment model in order to identify the informational and program needs for a reasonable release and aftercare process. The present reliance upon salvage of the poorly conceived release programs through ghettoization of ex-patients can only be justified as a mechanism for forcing a wide range of communities to accept long overdue responsibility for their disabled members.Professor of Geography and Urban Planning, Princeton University. Grateful acknowledgement is made to the NIMH (METRO Division) for research support to the Regional Science Research Institute (Philadelphia, Pa.), to the Center for Advanced Study in the Behavioral Sciences for fellowship support during the period this study was undertaken, and to Maurice Rappaport (Agnews State Hospital, Calif.), Harold Baker (Aftercare Services Division, Calif. Dept. of Health), Anthony Mumphrey, Daniel Garr (San Jose State University) and Montye Rivera (Home Care News, San Jose, Calif.) for their assistance in the conduct of this research.     

SCIENTIFIC‐BUREAUCRATIC MEDICINE AND UK HEALTH POLICY1

One prominent method for controlling health costs is to find measures for the management of demand. Various options exist for this; and many of them have been tried during the fifty years of the UK's National Health Service. Current policy now focuses on what may be called “scientific‐bureaucratic medicine.” This policy is based on the assumptions that valid medical knowledge is derived from accumulated research evidence and that such knowledge should be implemented through clinical guidelines which are enforced to some extent. This UK development has parallels with the US Agency for Health Care Policy and Research whose experience, therefore, raises some policy issues for the UK.     

Countercyclical U.S. fertility and its implications

The following article is the verbatim text of a report based on research funded by the Social Security Administration and the National Institute of Child Health and Human Development to the Rand Corporation. The report looks at changing fertility rates in the United States and their implications for future population size and age distributions. An economic model of fertility rate is used to explain observed differences in fertility rates amond couples and to predict future rates. The focus is on trends since 1947 because post-World War II data are the most complete. Several explanations for changing fertility rates are examined, and their usefulness in predicting the future is evaluated.     

Systems Changes Associated with Criminal Justice Treatment Networks

This article examines the ability of service networks to improve substance abuse treatment access and service delivery to adult, substance-abusing female offenders. In fiscal year 1995, the Center for Substance Abuse Treatment (part of the U.S. Department of Health and Human Services's Substance Abuse and Mental Health Services Administration) funded four demonstration projects to establish Criminal Justice Treatment Networks to improve substance abuse treatment access and service delivery to adult female offenders while they were involved in the criminal justice system. This study seeks to determine whether the networks promoted systemic change in the community agencies and organizations where they are housed. This article is based on a series of annual site visits, reports, and regular communication with network staff and local evaluators. The findings indicate that networks can improve service delivery in criminal justice and substance abuse treatment systems.     

Institutionalising a National Approach to Performance Reporting: Lessons from Two Decades of Experience with the Report on Government Services

The Report on Government Services (RoGS) to the Council of Australian Governments (COAG) is considered an exemplar of benchmarking in a federal system. Published annually since 1997, RoGS provides performance reporting in the form of cross jurisdictional benchmarking on an unprecedented scale and scope. This paper argues ROGS has institutionalised a national approach to performance measurement and reporting that is now at the centre of the COAG reform agenda. The paper examines the processes and institutional structures that explain how RoGS has transformed performance reporting for social infrastructure services. The final section provides a preliminary assessment of the impact of RoGS.     

Stewardship of quality of care in health systems: Core functions,common pitfalls,and potential solutions

National Ministries of Health in low‐ and middle‐income countries (LMICs) have a key role to play as stewards of the quality agenda in their health systems. This paper uses a previously developed six‐point framework for stewardship (strategy formulation, intersectoral collaboration, governance and accountability, health system design, policy and regulation, and intelligence generation) and identifies specific examples of activities in LMICs in each of these domains, pitfalls to avoid, and possible solutions to these pitfalls. Many LMICs now have quality strategies with clear vision statements. There are good examples of quality agencies and donor collaboration councils to coordinate activities across different sectors. There are multiple options for accountability, including public reporting, community accountability structures, results‐based payment, accreditation, and inspection. To improve health system design, available tools include decision support tools, task‐shifting models, supply chain management, and programs to train quality improvement staff. Policy options include legislation on disclosure of adverse events, and regulations to ensure skills of health care providers. Lastly, health information tools include patient registries, facility surveys, hospital discharge abstracts, standardized population and patient surveys, and dedicated agencies for reporting on quality. Policy‐makers can use this article to identify options for driving the quality agenda and address anticipated implementation barriers.     

The need for centres of health research excellence in the developing world

Pervasive ill health and overpopulation impede progress in most developing countries but in recent years, programs providing aid to these regions have de-emphasized health as a priority. Furthermore, support for building the health research capacity, so essential to the success of efforts to promote improved health, has been lacking. This paper examines these policies as they relate to one developing country, one global h ealth program and a major Canadian development agency. Much has been achieved in the past decade in one of the world's poorest countries, Bangladesh, but major health problems persist, particularly in maternal and child health. With the will to build effective health programs, Bangladesh lacks the resources and the research base needed for their development. The World Health Organization, (WHO) Diarrhoeal Disease Control (CDD) program, which addresses a major cause of child mortality in Bangladesh, promotes effective treatment but it contributes little to a permanent research establishment in that country. The Canadian International Development Agency (CIDA) which directs only a small portion of its $2.2 billion annual budget to health, lacks an influential level of technical expertise in health. This agency has no mandate to support health research in the developing world; research is the responsibility of the International Development Research Centre (IDRC), the Health Sciences Division of which closed in July, 1995. To upgrade the place of health and health research in development, the attitudes and policies of major donors must change and models of success are needed. Of the existing institutions or programs involved in health and health research in the developing world, the internationally funded health research centre, strategically sited in the developing world could provide the excellence around which relevant programs should flourish. An existing example of this rare species, the International Centre for Diarrhoeal Disease Research, Bangladesh, merits particular consideration in this regard.     

The Privatisation of Prisoner Transfer Services in Western Australia. What Can we Learn from the Ward Case?

In 2008, Aboriginal elder Mr Ward died of heat stroke while being transported in the back of a prison van operated by private security company GSL (now G4S). This article will address the role accountability mechanisms can play in improving correctional and custodial services and whether existing oversight frameworks can provide a proper supervision and quality control of private security operators. It will focus on the key reports issued by Western Australia's Inspector of Custodial Services, the independent office to oversee the prisoner transfer system. Another central source of information will be an examination of the report and recommendations handed down by the Western Australian Coroner Alastair Hope in June 2009. The Hope Report details the numerous failings of the system which led to the Ward tragedy. Both GSL and the Western Australian state government had breached a duty of care to Mr Ward. Further, it remains highly problematical having a range of oversight bodies if elected government is able to simply ignore the subsequent advice. Parliament must therefore remain a central part of the system of political accountability.     

The Social Security Administration's Death Master File: the completeness of death reporting at older ages

We examine the completeness of death reporting in the Social Security Administration's Death Master File (DMF) through comparison with deaths by year and age group reported in official U.S. vital statistics. For most years since 1973, results suggest that the DMF includes 93 percent to 96 percent of deaths of individuals aged 65 or older. Although studies have shown that the National Center for Health Statistics' National Death Index provides superior coverage of deaths, for many researchers the DMF may be a desirable choice. Some advantages of the Death Master File are discussed.     

Thinking Strategically in Federal Policy: Defining the Attributes of High‐level Policies

Governments frequently develop policies that are strategic in nature. Strategic issues at the national level are those requiring long timeframes for impact, coordinated approaches across multiple tiers of government, are cross‐sectoral, and require systemic approaches to design and implementation. Yet the process of how national strategic polices are developed and implemented in Australia is unclear, and largely unattended in the literature. This paper provides a foundation to understanding the characteristics of strategic polices and approaches to their development. Five national policies are compared (National Competition Policy, National Strategy for Ecologically Sustainable Development, the Strategic Roadmap for Australian Research Infrastructure, Australia in the Asian Century, and the National Food Plan) and discussed. An analytical framework is constructed and key attributes of strategic policy identified.     

Minerva: An electronic town hall

This paper presents the specifications for an electronic technology that will allow masses of citizens to have discussions with each other, and which will enable them to reach group decisions without leaving their homes. Specifications of the components needed are enumerated and a concrete system suggested. Possible variations and other uses of the system are explored.This study, supported by the National Science Foundation, project # GI-29940, is being carried out under the auspices of the Center for Policy Research. Dr. Stephen H. Unger is co-principal investigator with the author. Papers by Dr. Unger and other team members are available from Center for Policy Research, 475 Riverside Drive, New York, New York.     

Differential effects of high‐quality child care

In policy research a frequent aim is to estimate treatment effects separately by subgroups. This endeavor becomes a methodological challenge when the subgroups are defined by post‐treatment, rather than pre‐treatment, variables because if analyses are performed in the same way as with pre‐treatment variables, causal interpretations are no longer valid. The authors illustrate a new approach to this challenge within the context of the Infant Health and Development Program, a multisite randomized study that provided at‐risk children with intensive, center‐based child care. This strategy is used to examine the differential causal effects of access to high‐quality child care for children who would otherwise have participated in one of three child care options: no non‐maternal care, home‐based non‐maternal care, and center‐based care. Results of this study indicate that children participating in the first two types of care would have gained the most from high‐quality center‐based care and, moreover, would have more consistently retained the bulk of these positive benefits over time. These results may have implications for policy, particularly with regard to the debate about the potential implications of providing universal child care. © 2002 by the Association for Public Policy Analysis and Management.