Policy Information Center Highlights: Vol. 11, No. 1

01/01/2001

IN THIS ISSUE:


Evaluation of the Health Resources and Services Administration’s National Health Service Corps Program

The National Health Service Corps (NHSC) was established in 1971 under the Emergency Health Personnel Act of 1970 (P.L. 91-263) to improve the delivery of services in areas where health care professionals are in short supply. The program’s long-range goal is to build self-sufficient health care delivery systems in these communities chiefly by recruiting health care professionals (physicians, dentists, physician assistants, nurse practitioners, and certified nurse midwives, mental health professionals and dental hygienists) and placing them in medically underserved communities.

The report provides information about the factors that influence clinician motivations, experiences, and satisfaction; the contributions that clinicians make to their host sites and communities and the factors that influence their level of contri-butions; and clinician retention in underserved communities.

The results are based on two samples of alumni and current NHSC clinicians. Questionnaires were sent to 2,160 alumni clinicians and 1,143 currently serving clinicians. The response rates were 75.2 percent for current clinicians, 58.9 percent for alumni clinicians, and 62.1 percent for NHSC site administrators.

The findings suggest that the NHSC may need to focus more on the loan repayment program to meet the needs of underserved populations. The consistent pattern of more positive outcomes among loan repayment participants compared with scholarship recipients indicates that the loan repayment program has greater impact in achieving NHSC objectives.

The NHSC seems to achieve better outcomes in rural communities. The report suggests the smaller size of the communities and their organizations may enable young clinicians to make relatively important contributions in a short period, thereby enhancing their professional gratification. Better recognition and support of clinicians’ families might enhance retention and family integration into the local community.

The mix of health professionals supported by the NHSC, according to the report, should be strategically managed in response to both the requirements of communities and the specific health service delivery objectives of the NHSC and HRSA. Greater reliance on the loan repayment instead of the scholarship program would allow the NHSC to make more rapid adjustments to the mix of health professionals it enrolls and deploys, reflecting the expressed needs of communities and changes in HRSA’s strategic objectives.

Dentists play a crucial role in expanding access to care for underserved populations. Their role is not limited to oral health; they also provide more general clinical leadership in some settings. Continued, if not expanded, participation of dentists in the NHSC may be an important element in achieving HRSA’s overall policy objectives, particularly with the current expansions in publicly-sponsored dental insurance coverage (through SCHIP and Medicaid), which most certainly will create demand for dental services.

Contributions from NHSC include extending and expanding access to basic health care services and to improving the health care delivery system in underserved communities. This report documents those contributions. Outstanding among the contributions of NHSC clinicians are the substantial number of community-oriented primary care programs for a wide variety of population subgroups. The various programs have increased the volume and broadened the array of available services reaching new clients. Of at least equal importance is the “value-added” benefit of placing NHSC clinicians in underserved communities, where they have altered the very structure of the health care delivery system.

This report was prepared for the Bureau of Primary Health Care, HRSA, by Mathematica Policy Research, Inc. The project officer, Richard Niska, M.D., can be reached at (301) 594-4204. Copies of the final report, PIC ID#6357, can be obtained from the PIC.


Assessment of State Minority Health Infrastructure and Capacity to Address Issues of Health Disparity

This project, conducted by the Office of Minority Health (OMH), Office of Public Health and Science, assesses the minority health infrastructure in eight selected states and one territory to examine the capacity of these jurisdictions to address racial and ethnic disparities in health. The OMH priority health areas are: cancer; diabetes; cardiovascular disease; infant mortality; substance abuse; HIV/AIDS; and suicide, homicide, and unintentional injuries. The study also examined these cross-cutting infrastructure issues: 1) data collection and analysis; 2) cultural competence; 3) access to health care; and 4) health professions development.

The study was guided by seven key questions: 1) What are the efforts at the state level to eliminate health disparities, especially among racial and ethnic groups? 2) What are state-level efforts to eliminate or close the gap between racial and ethnic groups in the priority health issue areas? 3) What do states have in place to address each of the four cross-cutting infrastructure issue areas? 4) To what extent are state efforts linked to national efforts such as Healthy People 2000 or Healthy People 2010? 5) What characteristics of minority health entities hinder or contribute to their effectiveness? 6) What promotes and hinders the establishment and effectiveness of minority health entities? 7) Are efforts to “close the gap” in health disparities more likely to occur when dedicated minority health entities are established?

The methods used to answer these questions included: 1) site visits to all nine selected sites; and 2) the gathering of information at each site from at least four key informants. Key informants included directors of state health agencies, directors of state offices of minority health, legislators, governors, advisory councils, grassroots organizations, and other identified community groups.

There are many and varied activities currently implemented at the State level to eliminate disparities between the white population and racial and ethnic minorities, broadly characterized as: a) improving State capacity to respond to the health needs of minorities; b) promoting improved data collection, increased participation by minorities in the health professions, and improved access to culturally competent health services; and c) consulting with health departments and community-based organizations on how to decrease disparities in specific health conditions.

Findings show that outreach, the development of educational materials, and social marketing campaigns were the most frequently used strategies by state agencies and community-based organizations to address the health needs of minorities. The findings also indicated strong linkages between the minority health entity and minority communities, but less consistent linkages within and between state agencies, and between state agencies and the minority communities.

The study also found that there are factors that detract from the effectiveness and continuance of minority health entitities, such as lack of financial resources, isolation of the minority health entitities from other state agencies, and lack of legislative or regulatory grounding of minority health initiatives, and lack of data (data on the health conditions of minorities as well as to performance indicators).

The report concludes with some strategies which, if addressed in their entirety, could lead to substantial improvements in efforts at the state level to address racial and ethnic health disparities.

Recommendations

  • Launch an Initiative to Assist States in the Collection, Tracking, and Dissemination of Data on Health Status by Race and Ethnicity
  • Develop Initiatives to Assist States in Improving Inter- and Intra-Organizations Collaboration Related to Minority Health
  • Provide Technical Assistance to Improve State Health Infrastructures Particularly Related to Policies, Programs and Practices on Health Disparities
  • Sponsor a National Forum on Native American Health Care
  • Establish Regional Multi-State Initiatives on Areas of Common Concern
  • Increase Funding for Minority Health Initiatives at the State and Local Levels

This study was prepared for the Office of Minority Health by COSMOS Corporation. The project officer, Gerrie Maccannon, can be reached at (301) 443-5084. Copies of the final report, PIC ID# 7013, can be obtained from the PIC.


Reforming Welfare and Rewarding Work: A Summary of the Final Report on the Minnesota Family Investment Program

The Minnesota Family Investment Program (MFIP) represents a new vision of welfare as a system that can simultaneously encourage work, reduce dependence on public assistance, and reduce poverty. It attempts to break loose from the historical tradeoffs among these goals by implementing two complementary policies: financial incentives to reward work and reduce poverty and; mandatory participation in employment-focused services for long-term welfare recipients to encourage work and reduce dependence.

MFIP was initially implemented as a pilot program. The pilot program operated from April 1994 to June 1998, culminating in a modified version, is now Minnesota’s statewide welfare program. The final evaluation report consists of a summary report and two separate reports on the program’s impacts on adults (Volume 1) and children (Volume 2). Volume I examines MFIP’s effects on employment, earnings, welfare receipt, income, marrriage, and other outcomes for adults in single- and two-parent families for up to three years after they entered the study. Volume 2 presents the results of a special study of MFIP’s effects on children and other aspects of family well-being for single mothers who had at least one child aged 2 to 9 when they entered the study.

MFIP’s results are particularly important because more than 40 states have incorporated a “make work pay” approach in conjunction with work requirements as part of their new, time-limited welfare reforms, which followed federal enactment of the 1996 Personal Responsibility and Work Opportunities Reconciliation Act (PRWORA). Most commonly-as in MFIP-states have aimed to make work pay by increasing their “earned income disregard:” More of a family’s earnings are disregarded (not counted) when their welfare grant is calculated. This policy allows more people to combine work and welfare. The MFIP pilot program did not include time limits on welfare receipt, but the current modified statewide version does.

The evaluation used a random assignment research design. During the project period (1994-1996) more than 14,000 families in seven Minnesota counties were assigned, using a lottery-like process, to either the MFIP program or the traditional Aid to Families with Dependent Children program. MFIPs effects were estimated by following the two groups over time and comparing their employment, welfare receipt, and other outcomes. The difference in outcomes between the two groups is the effect, or impact, of the MFIP program.

Findings

  • For single-parent long-term recipients, MFIP had strikingly consistent positive effects across a range of adult, child, and family outcomes. It also led to some increase in welfare receipt and welfare costs.
  • For two-parent recipient families, MFIP reduced the financial pressure for both parents and increased marital stability.
  • MFIP did not increase family income for welfare applicants in two-parent families or recipients in two-parent families.
  • MFIP did not increase family income for either welfare applicants or recipients in two-parent families.

This study was prepared for ACF and ASPE by Manpower Research and Development Corporation. The project officer, Lawrence Wolf, can be reached at (202) 401-5084. Copies of the final report, PIC ID# 6824, can be obtained from the PIC.


Consumer Attitudes Toward Potential Changes in Food Standards of Identity

This report is a review of federal standards of identity regulations. On behalf of the Food and Drug Administration (FDA) and the U.S. Department of Agriculture, Food Safety and Inspection Service (USDA, FSIS), the Research Triangle Institute (RTI) investigated consumer attitudes toward standards of identity regulations.

In 1995, FDA announced that it planned to review its regulations pertaining to the identity, quality, and fill of container for standardized foods to determine which standards should be retained, revised, or revoked. In September 1996, FSIS published a similar announcement regarding its intent to consider changing or eliminating existing federal standards of identity for meat and poultry products. Both Agencies believe that manufacturers of standardized foods should have the ability to incorporate new food technology into standardized products and that some standards run counter to current nutritional science. FDA and FSIS would like to eliminate unnecessary detail in the standards while at the same time ensuring that consumers are protected from nutritional and economic fraud.

To investigate consumer attitudes toward standards of identity regulations, RTI conducted eight focus group discussions with household grocery shoppers in four locations (Raleigh, North Carolina; San Diego, California; Philadelphia, Pennsylvania; and St. Louis, Missouri).

Findings

  • Some participants felt standards are bad for consumers because they are: a) unnecessary, and b) costly to write and enforce. These participants considered truth-in-labeling laws adequate protection for consumers. These participants also felt that the laws of supply and demand, in combination with existing truth in labeling laws and nutritional and ingredient labeling, rendered standards of identity unnecessary.
  • Most people supported standards in a philosophical sense (i.e. found the argument for standards convincing and found the arguments against them unconvincing).
  • Most of the people who were opposed to standards did not think the laws of supply and demand would function to maintain the quality of foods, or felt that market forces would only work in the long run and were worried about what would happen in the short run.
  • Most participants had trouble seeing a downside to standards and, in particular, did not think their choices were being unduly restricted by standards. In fact, more people were concerned about the time it takes them to find products they like in the grocery store than about a lack of product choice. They were wary of trying to draw generalizations about when standards would be bad and instead felt that evaluating and revising standards could only be done on a case by case basis.
  • Most participants felt that FDA should get input from consumers about standards (when necessary and what requirements should be included) on a case by case basis they did not like the idea of FDA simply accepting revisions suggested by industrybecause they felt the purpose of standards was to keep industry in line.

This study was prepared by the Research Triangle Institute. The project officer, Clark Nardinelli, can be reached at (205) 872-6865. Copies of the final report, PIC ID# 6357, can be obtained from the PIC.


The Low-Wage Labor Market Challenges and Opportunities for Economic Self-Sufficiency

The low-wage labor market has come increasingly into the policy spotlight following welfare reform, as states strive to move welfare recipients into employment. This report synthesizes the current literature on the low-wage labor market and highlights some of the more challenging policy implications.

The report notes that classical labor market theory and theorists portray the labor market as a single unified market in which each worker is paid according to his/her value to the firm and is promoted to better-paid positions as that value increases. Today, however, many researchers believe that the low-wage labor market may be segregated from the primary labor market and may be structured quite differently, with few ladders to job advancement, little job stability, and more gender and racial discrimination.

The proportion of workers with low earnings is substantial. For example, 29 percent of all workers and 35 percent of female workers in 1997 had hourly wages that would be insufficient to lift a family of four out of poverty even if they were to work full-year, full-time. Also, according to the report, the share of workers with low or near-low earnings (below $7.50 an hour) rose from 36 percent in 1988 to over 41 percent in 1997.

The report includes a discussion of the policy implications regarding the wage, employment, and economic self–sufficiency outcomes of low–wage workers. For example, the labor market eventually will be able to absorb the influx of persons leaving the welfare rolls if the economy retains its current strength. However, in the short run, welfare recipients may have trouble finding employment. This difficulty will be particularly great in urban areas and regions where there are pockets of high unemployment.

Unfortunately, the jobs for which most welfare recipients qualify, because of low level of skills and education, are concentrated in the secondary labor market. This means low wages, few fringe benefits, little opportunity for advancement, and high job turnover.

The report concludes with a number of policy options for improving the wage, employment, and economic self-sufficiency outcomes of low-wage workers: (1) Continue funding and support for programs that provide labor market information, job networking, job retention counseling, and career planning. Services such as child care and transportation should not be overlooked.(2) Develop information networks and policies to encourage businesses to delineate skill requirements and career ladders for entry-level jobs, as well as on-the-job training for such career ladders. (3) Develop policies to raise the incomes of low-wage workers and enhance employment security, which would include the Earned Income Tax Credit, targeted public and community service jobs strategies, and minimum wage policies.

This study was prepared for the Assistant Secretary for Planning and Evaluation (ASPE) by the Urban Institute. The project officer, Kelleen Kaye, can be reached at (202) 401-6634. Copies of the final report, PIC ID# 7425, can be obtained from the PIC.


PLEASE NOTE!

Performance Improvement 2000: Evaluation Activities of the U.S. Department of Health and Human Services is now available on the PIC Website

The report is a compilation of HHS evaluations completed and in-progress during fiscal year 1999.


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 Juanita Butler, Technical Information Specialist, at 202-690-6445. Or E-mail PIC at: webmaster.aspe@hhs.gov

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