In This Issue:
- From Welfare to Work
- The AIDS Research Program of the National Institutes of Health
- Readiness to Expand Head Start Enrollment
- Policy Choices for Long-Term Care
FROM WELFARE TO WORK
In the late 1960s, Congress began reshaping Aid to Families with Dependent Children (AFDC),the nation's largest cash welfare program, to encourage employment among the heads of families receiving welfare, most of whom were single mothers. Evidence exists to support the claim that in many ways these programs succeeded. Overall, they increased the earnings of poor families and reduced government outlays. However, they did not eliminate welfare or poverty. The challenge for the 1990s is to make such programs work better and to determine whether greater investments in education and training will pay off in achieving higher-level skills and better jobs, in reducing long-term dependency, in strengthening families, and in improving outcomes for children.
The book, From Welfare to Work, summarizes what is known and what may be learned from completed and current studies about the impact and cost-effectiveness of welfare-to-work programs. It also discusses the different approaches used in these programs in varied local contexts and for various groups of AFDC recipients. The information collected for this book will be used in an eight-year evaluation of the Job Opportunities and Basic Skills Training (JOBS) Program, which is the focus of the 1988 Family Support Act, to increase poor families' self-sufficiency.
Three key lessons can be extracted from the research on past studies and applied to the JOBS Program. First, different services and program models have different payoffs for particular groups within the welfare population, so targeting resources where they are likely to count most is central to JOBS planning. Second, there may be trade-offs in meeting program goals -- notably, in reducing welfare expenditures and in maximizing the earnings of the people served in welfare-to-work programs. And third, understanding the magnitude of possible effects of JOBS, and how such effects are achieved, is essential to resource allocation decisions.
This study was conducted by the Manpower Demonstration Research Corporation, under contract with the Office of the Assistant Secretary for Planning and Evaluation and the Ford Foundation. The study's project officer, Canta Pian, can be reached on 202-245-1880. Copies of the executive summary, #4174, are available from PIC.
THE AIDS RESEARCH PROGRAM OF THE NATIONAL INSTITUTES OF HEALTH
In the 1980s, the National Institutes of Health (NIH) faced an unprecedented challenge of responding to the epidemic of human immunodeficiency virus (HIV) infection and the acquired deficiency syndrome (AIDS).
When the magnitude of the epidemic became clear -- especially when HIV was identified as the causal agent -- NIH was given the mandate and resources to develop a large, multifaceted AIDS research program to understand the virus's pathogenesis, discover and test therapies, and develop prevention strategies and a vaccine. Although research supported and conducted by NIH has led to rapid increases in basic knowledge about HIV and AIDS, much remains unknown.
The report, The AIDS Research Program of the National Institutes of Health, reviews the NIH AIDS program, giving particular attention to its scope and content, management, results, and levels of budgetary and administrative support. It presents recommendations for strengthening current efforts as well as for identifying the program's future directions.
To conduct the study, a 15-member committee of experts convened in December 1989 for a hearing and invited testimony from representatives of several AIDS-related groups. The committee also reviewed a series of background papers presenting information based on research and interviews with 150 NIH and PHS officials, researchers, and congressional staff.
The committee recommended that NIH complete the development of its AIDS program as a comprehensive, long-term effort and develop a five-year plan to identify AIDS-related research needs, set priorities, determine the resources needed to continue the program, and evaluate the progress of the program. It also recommended that NIH expand its HIV vaccine research program; reassess its epidemiologic research priorities; evaluate ongoing research; and expand studies on groups that have high rates of HIV infection. The committee also advises NIH to increase support for research that examines the behaviors encouraging HIV transmission, including human sexual development and practices, drug addiction, and drug abuse. The committee concluded that funding for AIDS research be increased.
The study was conducted by the National Academy of Sciences, Institute of Medicine. The study's project officer, Marc S. Horowitz, can be reached on 301-402-0852. Copies of the executive summary, #4119, are available from PIC.
READINESS TO EXPAND HEAD START ENROLLMENT>
The national Head Start program, now in its 26th year, continues to grow substantially. In FY 1991, Head Start reached nearly 600,000 children in total enrollment and commanded $1.95 billion in funding. For FY 1992, Congress has appropriated approximately $2.06 billion for Head Start funding. For FYs 1992-1994, reauthorizing legislation projects expansion funding of $4.27 billion, $5.92 billion, and $7.66 billion, respectively. Concerns exist, however, about Head Start's capacity to expand as rapidly as the increasing appropriations will allow.
The inspection, Readiness to Expand Head Start Enrollment, assesses Head Start's capacity to successfully manage the current and future enrollment expansion process. The Office of Inspector General (OIG) conducted structured interviews with a stratified random sample of grantee agencies that carry out the program's objectives with selected staff of the Office of Human Development Services (OHDS), now part of the Administration for Children and Families. The interviewees included representatives from 75 of the 1,140 grantee agencies that received enrollment expansion awards in 1990 (plus 2 additional large grantees) and OHDS staff members, including 5 or 6 OHDS staff from each of the 10 regions and 6 OHDS staff from headquarters. The questions elicited data and perceptions based on the interviewees' experience with enrollment expansion in 1990 and their plans and ability to handle further expansion in 1991.
Grantees reported that they met their enrollment expansion goals for the first round of 1990 expansion and that they planned to fully meet their goals for the second round by September 1991. Grantees also reported few problems with the 1990 grant process.
Seventy-five percent of the grantees interviewed planned to apply for FY 1991 expansion funds. Sixteen percent felt they were not ready to expand. Almost all indicated that substantial numbers of children are not served in their service areas.
Need for additional space to accommodate the anticipated expansion posed a major problem for 80 percent of the grantees interviewed. The space problem was most prevalent among grantees that were funded to increase enrollment by more than 200 children in each round. Grantees often cited the obstacles of strict licensing requirements and delays in license approval. Enough advanced notification, grantees believed, would allow them to acquire the necessary space in time to avoid major crowding problems.
A lesser problem presented by expansion was the need to hire more teachers and support staff and to obtain more transportation.
Most grantees expected expansion funds to raise the quality of services. Of the two-thirds that held this view, a majority expressed it without qualification, but others felt it was contingent upon monies being allocated for quality enhancements such as increased staff salaries and benefits.
In contrast, slightly more than half of the regional and headquarters OHDS staff doubted that expansion funds will enable grantees to maintain or improve the quality of their services. They questioned whether allocations for salaries and costs per child will be sufficient, whether grantees will have the capacity to maintain quality, and whether federal staff will be able to evaluate grantee quality.
Federal capacity to manage the expansion appears limited. Fifty percent of regional staff felt there was too little time and insufficient staff to adequately help grantees prepare applications in each round.
Enrollment expansion necessitates that both regional and headquarters staff provide technical assistance to grantees and perform comprehensive monitoring, which dictates that they conduct more onsite visits than are currently possible. Although staff size and grantee workloads vary widely among the regional and headquarters offices, 80 percent of both reported that they lack sufficient travel funds and staff to monitor and assist grantees in the coming enrollment expansion effort.
Another issue that surfaced during the interviews was that federal staff lack timely information on grantee expansion progress. They rely primarily on an annual report they receive from grantees every June. They can only verify this information during onsite visits, which are typically made to grantees no more than once every three years.
In addition, more than 50 percent of the Head Start managers considered communication between headquarters and regional offices less efficient and effective as they would like. They also expressed concern about the organizational structure of Head Start. Problems resulted from operating the regional Head Start staff under the OHDS Office of Community Programs (which existed only in the regions) and operating the headquarters staff under the Administration for Children, Youth, and Families (which does not exist in the regions). This situation caused unnecessary delays in processing policy developments and funding guidelines. It also has been problematic during the enrollment expansion. The recent creation of the Administration for Children and Families, which has absorbed OHDS, may lead to organizational changes that will correct some of these problems.
The inspection was conducted by the Office of Inspector General. Copies of the executive summary, #4177, are available from PIC.
POLICY CHOICES FOR LONG-TERM CARE
Spending on long-term care services primarily for people with chronic illnesses or functional limitations totaled an estimated $57.8 billion in FY 1988. Under current financing arrangements, some analysts project that such spending could triple over the next three decades, even after adjusting for general inflation. The aging of the baby-boom generation, improvements in life expectancy, and rates of price increase for labor-intensive services that exceed the rates of general inflation imply that a greater share of both federal and total spending will be directed toward long-term care if the public role in financing services and current usage patterns remain unchanged. Two divergent views have emerged: Some policymakers argue that total public and private spending for long-term care is already too high and current demographic trends will only worsen matters. Other policymakers argue that many people who need long-term care services currently have too little access to appropriate care and that the system currently places insufficient emphasis on maintaining people's capacity for independent living.
The report, Policy Choices for Long-Term Care, offers a conceptual framework for analyzing policy choices for long-term care. In particular, it addresses the projected growth in federal and total spending on long-term care under current law. It also examines alternative ways to increase financial protection for people who require extensive care and to broaden the range of services available to them.
Five possible approaches to containing federal long-term care costs are discussed: cost sharing, systems for reimbursing providers, managed care and case management, regulation of supply, and changes in program scope. To contain costs, the proportion of the total population covered by the programs and the participation rate among those individuals covered need to decrease. A balance of high-cost and low-cost services also needs to be established. And ultimately the federal government needs to pay a smaller proportion of the cost for each service.
Total spending for long-term care is expected to increase significantly in coming decades, although specific projections vary substantially. The variation in projections, particularly in long-term projections, results from considerable uncertainty about demographic factors, medical care prices, and intensity of services.
The report presents four sets of choices that need to be made regarding financial protection for individuals. The choices involve identifying the mechanism for providing financial protection, services to be covered, specific groups to be targeted for public assistance, and division of responsibility between the public and private sectors and among the various levels of government.
The report offers two broad approaches to modifying the long-term care system. One approach would retain both the current division of responsibility for long-term care and Medicaid's basic character as an income-tested and asset-tested program. It would address specific problems in the design of the Medicaid program through changes that could be implemented incrementally, depending on priorities and the availability of funds. The other broad approach would more fundamentally restructure the financing and delivery of long-term care. In the process, it would substantially modify the division of responsibility for that care among the private sector, state governments, and federal governments.
Copies of the executive summary, #4116, are available from PIC.
SERVICES AVAILABLE FROM THE PIC
The Policy Information Center (PIC) is a centralized source of information on in-process, completed, and on-going evaluations; short-term evaluative research and; policy-oriented projects conducted by HHS as well as other Federal departments and agencies. The PIC on-line database provides project descriptions of these studies. It is available on-line at: http://aspe.hhs.gov/PIC/. Inquiries regarding PIC services should be directed to Carolyn Solomon, Technical Information Specialist, at 202-690-5694. Or E-mail PIC at: webmaster.aspe@hhs.gov