The State of American Federalism, 1996-1997

Federalism enjoyed political and popular salience during theperiod 1996–1997 as the so-called "Devolution Revolution"began to be implemented and analyzed in the United States. Whilethere were a few examples of important Revolutionary efforts,the federal government continued to hold much of the power andsignificance it has achieved over the past sixty years. Evenin the area of welfare policy, where in 1996 there were historicreforms enacted to end the federal entitlement, the federalgovernment maintained a significant presence that made the ideaof devolution of welfare policy responsibility some what questionable.Nevertheless, states continued to lead in policy innovationin areas ranging from education to health, and the U.S. SupremeCourt continued to question the limits of federal power. Thepast year illustrated, once again, the complexity of our federalsystem and how difficult it is to reform federalism—particularlywhen it involves a shift in power and creates the perceptionof winners and losers.     

The government's best offense is deference: the decision of the Supreme Court in Shalala v. Guernsey Memorial Hospital

The United States Supreme Court agreed with the Secretary of Health and Human Services that Guernsey Memorial Hospital's advance refunding transaction costs would be subject to a medicare reimbursement policy that is not based upon generally accepted accounting principles. According to the sharp dissent in this case, this policy, set forth in a manual provision, contradicts federal regulations.     

Evaluating adolescent decision making in legal contexts

Challenges the use by policy researchers of a model for comparing adolescent and adult decision making that is based on informed consent standards. An expanded decision-making framework designed to evaluate judgment in adults and adolescents can better test the empirical basis of paternalistic legal policies. The theoretical and empirical literature on the informed consent framework is critiqued and an alternative framework incorporating judgment factors is proposed. Three judgment factors—temporal perspective, attitude toward risk, and peer and parental influence—and their effects on decision making are explored. Finally, implications for future research are analyzed in several decision-making contexts.Several of the ideas in this article were originally presented by the first author and were published as part of a symposium on competence (see Scott, 1992). The current article expands and refines these ideas, provides a more substantial research base, and suggests several future research directions. We thank Joseph Allen, Richard Bonnie, Baruch Fischhoff, William Gardner, John Monahan, Edward Mulvey, Richard Redding, Paul Slovic, and three anonymous reviewers for their helpful comments. Special thanks to Thomas Grisso for providing much constructive criticism and to Wendy Shang for outstanding research assistance. Finally, we would like to acknowledge the MacArthur Foundation, which supported this work in its early stages.     

The Department of Health and Human Services issues proposed regulations on physician incentive payments by hospitals

Hospitals tempted to operate their own physician incentive plans are reminded that, under OBRA 1986, they are precluded from paying physician incentives of any kind to reduce or limit Medicare or Medicaid covered services. In light of the proposed regulations and the guidance of the preamble, hospitals should review their incentive plans to determine whether physicians providing direct patient care are receiving prohibited payments. Further, supervising physicians who are receiving incentives for certain hospital departments may not influence direct care over patients served by those departments, even through other physicians. Some risk may also exist if incentives are based on a formula that considers patients of the supervising physician's medical group. Finally, it may be useful to develop a utilization and quality of care review program specifically designed to assure that patient undertreatment does not occur as a result of any supervising physician incentive program.