Bending the health cost curve: the promise and peril of the Independent Payment Advisory Board

Underlying today's and the future's health-care reform debate is a consensus that America's health-care financing system is in a slow-moving but deep crisis: care appears substandard in comparison with other advanced industrial countries, and relative costs are exploding beyond all reasonable measures. The Obama Administration's Patient Protection and Affordable Care Act (ACA) attempts to grapple with both of these problems. One of ACA's key instrumentalities is the Independent Payment Advisory Board-the IPAB, designed to discover and authorize ways to reduce the rate of growth of Medicare and other categories of health spending. The IPAB is a peril. Expert boards to perform regulatory tasks in the interest of efficiency and social goals always run a high risk of being captured by the industry they are supposed to regulate. Even should it succeed at its task of reducing the rate of growth of Medicare spending, who is to say that the reductions will not come at a heavy cost in reduced quantity and effectiveness of medical care? But the IPAB also has promise. The need for a better process than our current specialist-driven one to assign value to the medical services provided by Medicare is great. The bellwether status of Medicare payment systems means that commercial insurance consumers and payors would also benefit mightily from bringing more coherent, technocratic, and cost-effectiveness oriented logic to this process. And the current system of relative Medicare reimbursement rates is, in the judgment of many, currently well out of whack. We quail when we consider the magnitude of the tasks the IPAB faces--even its initial task. Nevertheless, we remain optimistic that this administrative agency will manage to bend the long-run healthcare cost curve and moderate future price increases.     

TURNING OFFENDERS INTO RESPONSIBLE PARENTS AND CHILD SUPPORT PAYERS*

This article describes four demonstration projects that strive to promote responsible behavior with respect to parenting, child support payment, and employment among incarcerated and paroled parents with child support obligations. These projects, conducted in Colorado, Illinois, Massachusetts, and Texas, with support from the federal Office of Child Support Enforcement and evaluated by the Center for Policy Research, led to a number of common outcomes and lessons. The projects revealed that inmates want help with child support, parenting, and employment and that prisons can be effective settings in which to conduct such interventions. Family reintegration programs were popular with inmates and may have helped to avoid the rupture of parent–child relationships commonly associated with incarceration. Although employment is the key to child support payment following release, rates of postrelease employment and earnings at all project sites were low and the employment programs were of limited utility in helping released offenders find jobs. Agencies dealing with child support, employment, and criminal justice need to adopt more effective policies with incarcerated parents including transitional job programs that guarantee immediate, subsidized employment upon release, child support guidelines that adjust for low earnings, and better training and education opportunities during incarceration.     

Is technological innovativeness one behavior or many?

A major criticism of research on technological innovation is the inconsistency of findings across studies. One explanation for this inconsistency may be the multiple conceptualizations of innovation used in the literature. In this study, four behaviors of innovativeness are reviewed. Factors affecting each behavior are then empirically examined indicating that the behaviors result from different factors. To ensure that future research does not simply create mini-theories of different aspects of innovation, a schema for integrating the different conceptualizations is proposed. Results of an illustrative analysis using this schema is then presented.     

The Crime and Threat Image Set (CaTIS): a validated stimulus set to experimentally explore fear of crime

Objectives

Fear of crime may develop in response to crime specifically (the narrow pathway) or may be a projection of broader threats (the broad pathway). New approaches are needed to examine how crime and threat, independently and in combination, influence people’s fear. To address this need, we created, evaluated, and validated an image set that varied across the dimensions of threat and crime.

Method

We used a 2 (Threat: high vs. low) × 2 (Crime: high vs. low) within-subjects factorial design. In three studies, participants (N = 24, 29, and 176, respectively) gave threat, crime, and fear ratings towards images. Participants also completed two traditional fear of crime measures and a measure of anxiety. Two evaluation studies explored the suitability of 178 images to produce a final set of 80 images (20 in each of the four categories). We validated this final set of 80 images in a third study.

Results

The validated Crime and Threat Image Set (CaTIS) contains 78 images across four categories: threat-and-crime (high-crime, high-threat), threat-only (low-crime, high-threat), crime-only (high-crime, low-threat), and neutral (low-crime, low-threat). There were significant main effects of threat and crime, and an interaction between Threat × Crime, on participants’ fear ratings. Participants’ own ratings of threat—but not crime—had a strong relationship with their fear ratings.

Conclusions

Threat had a stronger influence on participants’ fear ratings than crime. Thus, what is typically referred to as fear of crime may reflect broader fear. Further research with the CaTIS could explore the expression of this fear.

     

The Common Sense of Anti-Indian Racism: Reactions to Mashantucket Pequot Success in Gaming and Acknowledgment

Anti-Indian racism, as typified by anticasino backlash, is a part of the "common sense" of race relations in the United States, which increasingly impacts federal administrative procedures used to acknowledge the existence of tribal status. Using ethnographic and archival research, this article shows that the backlash over Mashantucket Pequot recognition and casino success has taken the form, primarily, of racialized attacks on the Mashantucket Pequots' Indian identity. It argues that such backlash carries over to impact groups who seek recognition of their tribal status, and the legitimation that such recognition might bring to their identity. Examining the colonial legacies of anti-Indian racism shows us that such racial antagonism in the United States is nothing new. However, understanding the contexts within which its recent resurgence has occurred may help bring fairness to the acknowledgment process, and may further illuminate intersections of common sense racism and legal spheres in American life.     

Benefits and burdens: Does it really matterWhat we allocate?

There is growing, evidence that allocation decisions concerning burdens and benefits are not processed equivalently. This paper suggests three dimensions on which information processing for resource allocations differs: status quo effects (individuals react more strongly to losses in status quo than to gains), resource valence effects (individuals react more strongly to resource allocations involving burdens than those involving benefits), and blame effects (individuals react more strongly to resource allocation decisions in which they exercise choice). Results of an empirical study confirm significant differences in the information processing of burdens and benefits, and also confirm the importance of psychological distance in the reactions of individuals to burdens and benefits allocations.For there is nothing either good or bad but thinking makes it so.-Hamlet (William Shakespeare)     

The value of reducing risks of death: A note on new evidence

Government agencies face difficult resource-allocation decisions when confronted with projects that will reduce risks of fatality. Evidence from individual behavior helps determine society's values for reducing risks. The most credible evidence is based on individuals' willingness to pay (or willingness to accept compensation) for small changes in risks. Studies of consumer behavior are limited, but more evidence is available relating wages to job risks. Contingent valuation studies reinforce the wage-risk implications, leading to a range of values that can be compared with the costs of proposals to reduce fatal risks.