PPS waivers: implications for Medicare, Medicaid, and commercial insurers

This paper compares the Medicare prospective payment system (PPS) to four all-payer rate-setting systems that operated under HCFA waiver authority. The study examines the experience of Medicare, Medicaid, and commercial insurers under the two approaches. Data from several American Hospital Association surveys and from Medicaid 2082 report forms are analyzed. The paper concludes that the all-payer waiver programs have been as successful as PPS in controlling the rate of growth in Medicare costs. In addition, Medicaid programs are more successful in controlling their outlays in all-payer rate-setting environments than when they "go alone." Finally, there is no evidence to suggest that hospitals can increase charges in response to greater financial need under either PPS or the state waivers. Nevertheless, it appears that commercial insurers are better able to compete with Blue Cross plans in all-payer rate-setting states than elsewhere.     

Assessment of competency for execution? A guide for mental health professionals

Assessment of competency for execution presents two compelling ethical questions for mental health professionals: whether clinicians can ethically provide such assessment, and if so, how it should be done in order to maximize quality and minimize ethical conflict. In this article we address the issue of whether to participate and, if so, how. The question of whether to participate is discussed by summarizing the arguments for and against participation and offering guidelines for making a decision. The question of how to proceed is discussed in two contexts: preadjudication (before a formal decision about competency) and postadjudication (following a determination of "incompetent" and transfer of the offender to another facility for treatment and further assessment). Finally, recommendations are made regarding research that would improve the quality of execution competency assessments.     

Garcia and the Political Safeguards of Federalism: Is There a Better Solution to the Conundrum of the Tenth Amendment?

In Garcia v. San Antonio Metropolitan Transit Authority (1985),Justice Harry Blackmun held that the Tenth Amendment does notprevent the Congress from subjecting state and local governmentsto the provisions of the Fair Labor Standards Act, concludingthat the "political safeguards offederalism" are generally adequateto protect state interests on the national scene. This articleexamines the intellectual foundations of the "political safeguardsof federalism" and finds them inadequate. It then surveys thepost-Garcia scholarship to ascertain whether an alternativetheory of the Tenth Amendment has emerged. Concluding that ithas not, the author suggests the need for afresh approach inview of the hints contained in Justice Sandra Day O'Connor'sopinion in Gregory v. Ashcroft (1991) that five justices maybe ready to reexamine the central thesis of Garcia.     

Medicaid in the 1990s: Trends, Innovations, and the Future of the "PAC-Man" of State Budgets

Rapidly escalating health-care inflation and congressionallymandated expansions have led to large increases in spendingfor Medicaid, the federal-state program of health care for thepoor. These increases came at a time when state budgets werealready under recession-induced stresses. In addition, 1991brought new pressures for Medicaid spending from the courtsand closer federal scrutiny and control over revenues used forthe program's state "match." Yet the Medicaid picture is farfrom bleak. Diversity, innovation, and an emerging stale policyrole also characterize the program in ways that epitomize thestrengths and weaknesses of the American intergovernmental system.     

Impersonal influence: Effects of representations of public opinion on political attitudes

Many phenomena of interest to political scientists involve what may be termed impersonal influence; that is, influence that derives from individuals' perceptions of others' attitudes, beliefs, or experiences. Others in this case refers not to the close friends and acquaintances that concerned the authors of classics such asThe People's Choice andPersonal Influence, but rather to the anonymous others outside an individual's realm of personal contacts. Modern mass media facilitate the influence of anonymous others by devoting considerable time and attention to portraying trends in mass opinion. This study explores the rationale for theories of impersonal influence, synthesizing existing research findings falling under this general theoretical framework, and investigating its psychological underpinnings using experiments embedded in representative surveys.