Public policy最新文献

The search for better ways to care for the chronically ill elderly has led to "alternatives to institutional care." A study fo geriatric day care and homemaker services finds that they were used as an add-on to existing care, few patients benefited, and costs were 60-71% higher than costs of a control group. Four more studies have confirmed the lack of substitution effects. Services could be targeted on those who need them even though it is very difficult to do so, and efficacy should be demonstrated before benefits are expended to new services.

In adopting, implementing, and enforcing regulation, various costs are incurred that typically are not included in benefit-cost analyses. These costs include private and public administrative costs, political activity costs, and growth costs. We estimate these indirect costs to be from 20 to 38 percent of the direct costs of complying with regulations. For pollution control regulations, the range is 22-29 percent. Analysis of 20 Inflation Impact Statements indicates that in all cases the regulating agency neglects these indirect costs. This neglect can lead ceterus paribus to overlie stringent regulations and to adoption of regulations with negative net benefits.

This article inquires into structural and operational characteristics of nursing homes that have predictive power for the quality of direct patient care provided to their residents. Data are from nursing homes in the Phoenix, Arizona, metropolitan area. The data were analyzed using multivariate linear regression. Findings of policy interest are that, other things equal: (1) for-profit facilities provide lower levels of care than do nonprofit facilities; and (2) distantly headquartered chain operations provide lower care levels than locally owned facilities. These factors should be considered in long-term care planning and regulation.

Distribution of federal funds has achieved equal status with Congressional reapportionment as a motivation and justification for the Census of Population and Housing. This article describes the effects that U.S. population redistribution during the 1970s, as measured by the 1980 Census, will have on the spatial distribution of federal grants-in-aid provided to state and local governments through programs with formula-based funding systems. The conclusion is that funding changes will not match population changes. The overall redistribution of federal grants-in-aid to state and local governments occurring in response to incorporation of 1980 Census population counts into federal funding formulas will be far less than the level of population redistribution since 1970. Use of intercensal data, formula specifications, limited geographic specificity in many formula allocations, and nonformula determinants of formula-based grants all weaken the relationship between Census-measured population change and the receipt of federal funds at the local level. Despite all the intervening factors, it is probably that in many programs there will be some redistribution of funds when the 1980 Census counts are incorporated into the allocation formulas. But the importance of measurement errors and threshold and reclassification effects may equal that of true population change in determining the funds received by local communities.

In recent years, equity, choice, and efficiency issues in the provision of education have received much attention and analysis. Yet, in the area of other state services for children (health, protective services, day care, etc.), there has been scant concern for equity, efficiency, or choice, despite the fact that out-of-school influences can be crucial in determining in-school performance. This paper reports on work in progress that reaches the following initial conclusions: 1. In the field of children's social services, data compilation is approximately 20 years behind the state of the art for education. Basic data on services provided is not collected for submission to state or federal authorities in any standard format on a recurring basis. 2. From the limited data available, the access of children to quantity and quality in social service programs varies enormously within states. The variations are much larger than those discovered in the public financing of education even before the recent school finance reform movement (1968-1978). 3. Federal allocations to states for social service programs comprise a substantial proportion of state Title XX budgets. For several reasons, the degree of accountability for these funds is less than that for federal education grants. 4. In all three states Title XX state allocations to localities are purported to be based on need. Closer examination of the formulas, and interviews with policy makers, revealed that Title XX allocations are determined primarily by political criteria.

Current regulatory practice seeks to reduce the supply of nursing home beds in areas that rank high in number of beds per capita. The presumption is that a high rank signals "overbedding," i.e., an excess of beds over need. A model of service use is employed to interpret data on the appropriateness of skilled nursing facility (SNF) utilization by Medicaid patients. The analysis reveals that beds per capita is a poor indicator of the relative probability that an area is overbedded, and suggests a more discriminating response to variations in the supply of SNF beds.

A framework is presented for examining obstacles to the implementation of human services delivery programs. These obstacles appear to arise from three basic sources: (1) from the operational demands implied by a particular program concept, (2) from the nature and availability of the resources required to run the program, and (3) from the need to share authority with, or retain support of, other bureaucratic and political actors in the implementation process. Within these three broad categories, fifteen areas deserve special attention: the people to be served, the nature of the service, the likelihood of distortions or irregularities, the controllability of the program, money, personnel, space, supplies and technical equipment, and intersections with overhead agencies, other line agencies, elected politicians, higher levels of government, private-sector providers, special-interest groups, and the press. By searching each of these fifteen areas diligently and systematically--with the aid of some 44 "factors for consideration"--it appears possible to make relatively powerful predictions about the obstacles that the implementation of a given human services program will entail. In addition, the framework can be used as a comparative instrument in allocating scarce political, managerial, and financial resources among human services programs, and as an aid to decision-making within particular programs and to identifying obstacles that cut across programs. Finally, some general guidance is offered on how implementing agency managers might deal with one of the more important and difficult dimensions of program implementation--namely, getting the cooperation of players in the implementation game whom the managers do not control, and who have different interests and agendas.

Consideration of the analytic difficulties faced in estimating the benefits and costs of prenatal genetic diagnosis, coupled with a brief review of existing benefit-cost studies, leads to the conclusion that public subsidy of prenatal testing can yield benefits substantially in excess of costs. The practical obstacles to such programs include the attitudes of prospective parents, a lack of knowledge, monetary barriers, inadequately organized medical resources, and the political issue of abortion. Policy analysis can now nevertheless formulate principles and guide immediate actions to improve present utilization of prenatal testing and to facilitate possible future expansion of these diagnostic techniques.

Illness or disability is often used as an eligibility criterion by public programs that distribute money, services, privileges, and exemptions. Physicians then play a central role in the allocation process. But physicians are caught between a large pool of applicants who want some benefit, on the one hand, and an organization with limited resources to distribute, on the other hand. Three conflicts are engendered in this gatekeeping role: the tension between trusting and mistrusting information provided by the patient, the tension between erring on the false positive side and the false negative side in diagnostic decision-making, and the tension between doing everything possible for each patient and allocating limited resources among several needy clients. Several non-medical factors influence the ultimate outcome of this allocation process, which, in theory, rests on clinical decision-making: the specificity and restrictiveness of the formal definitions of illness and disability used by a program; the structure of the determination process; the overall policy of the organization on distribution of benefits; and the ability of the organization to use administrative review, direct incentives, and written standards to control the certifying behavior of physicians.