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.     

Situational variation in moral judgment: In a stage or on a stage?

Two issues were examined in this study—the consistency of moral judgment across different types of dilemma and different social contexts, and the relationship between the structure (stage) of moral judgment and the content of moral decisions. Forty subjects were given two hypothetical dilemmas about business decisions and two standard Kohlberg dilemmas. Half the subjects directed their responses to a business audience, half to a philosophical audience. Responses to the moral dilemmas were scored in accordance with the Colby and Kohlberg (1987) scoring manual. Stage of moral reasoning was found to be significantly higher on the Kohlberg dilemmas than on the business dilemmas. A significant interaction between type of dilemma and audience was attributed to the tendency of subjects directing their responses to a business audience to interpret one of the business dilemmas in terms of the moral order of business, but for subjects directing their responses to a philosophy audience to treat it as a philosophical dilemma. The other business dilemma evoked uniformly low-level moral judgments. The amount of selfishness intrinsic in subjects' moral choices on the business dilemmas was significantly negatively correlated with moral maturity on the business dilemmas, but not with their moral maturity on Kohlberg's test. These results are interpreted as more consistent with models of moral development such as those advanced by C. G. Levine ([1979] Stage Acquisition and Stage Use: An Appraisal of Stage Displacement Explanations of Variation in Moral Reasoning, Human Development, Vol. 22, pp. 145–164), J. Rest ([1983] Morality, in: P. H. Mussen [ed.], J. H. Flavell and E. Markman [Vol. eds.], Handbook of Child Psychology [Vol. 3, 4th ed.], John Wiley & Sons, New York), and R. Harré ([1984]) Personal Being: A Theory for Individual Psychology, Harvard University Press, Cambridge, Massachusetts), which posit a relatively wide range of within-person stage use and emphasize the determining power of social situations, than with the more constructivistic model of moral development of Colby and Kohlberg (1987).This research was supported by Grant No. 410-87-1115 from the Social Sciences and Humanities Research Council of Canada.Received B.A. and M.A from Simon Fraser University. Research interests include moral development, and the influence of social interaction and language on the development of reasoning.Received Ph.D. from Harvard University. Research interests include moral development, altruism, and self-deception.     

Danger: implants

The superheated debate over breast implants awakened a sleeping giant of an issue clouding "medical devices"--the government's clumsy nomenclature for any medical product that is not a drug, from breast implants and artificial hips to X-ray machines and surgical thread. Some 130 categories of high-risk devices are in use with little or no proof of safety, reliability or effectiveness. All appeared before 1976, the year that the Food and Drug Administration got the authority to regulate such products. Under activist chief David Kessler and with added clout from a 1990 law, the FDA plans to scrutinize the entire 130-item list. Five will get special attention starting early next year: saline-filled breast implants, inflatable penile implants, testicular implants, heart-bypass pumps and cranial stimulators. U.S. News has looked at all five devices, using FDA data obtained through the Freedom of Information Act. In-depth computer analysis suggested that penile implants deserve closer examination. Why is clear from the following report.