In This Issue:
- Background Papers on Welfare Reform: Child Support Enforcement
- Services for Migrant Children in the Health, Social Services, and Education Systems
- Beneficiary Perspectives of Medicare Risk HMOs
- Review of State Legislation Related to Increasing the Training, Supply, Recruitment, and Retention of Generalist Physicians, 1985-1991
- Simulation of Trends in Employment, Welfare, and Related Dynamics (STEWARD)
A recent study conducted by the Urban Institute concluded that, if child support orders reflecting a parent's ability to pay were established and enforced for all children with a living noncustodial father, aggregate child support payments would have been as high as $47.6 billion dollars in 1990. This figure is three times the amount actually paid by fathers in 1990. Thus, there is a gap between current and theoretically possible collections of $33.7 billion dollars. The study asserts that there are three primary reasons for this gap. Not all existing awards are paid; awards are generally inadequate; and many potentially eligible custodial parents do not have a legal child support award or order.
The report, Background Papers on Welfare Reform: Child Support Enforcement, examines child support enforcement (CSE) from several angles. It discusses the changing nature of the family structure which has given rise to ever greater proportions of children living in single- parent homes, provides information on the CSE system, and discusses areas in need of reform.
Although the total number of children under the age of 18 has been stable since 1960, the number affected by divorce, separation, and unwed parents continues to rise. In 1991, 14.6 million children lived in a female- headed family-- almost 3 times their number in 1960. Most of this increase may be attributed to the increasing numbers of out-of-wedlock births during the 1980s. During that decade, the number of these births increased by 75 percent.
The rising numbers of children living in single-parent homes, regardless of the reason, face many difficulties. Children in these families are five times more likely to be poor than children in two-parent families. Moreover, they are likely to remain in poverty for longer periods than other poor children. Children of teen mothers are particularly susceptible to long-term poverty. The concentration of responsibility on single parents and the traditionally lower wages for women seriously curtail the amount of money a single mother can earn. Exacerbating these difficulties is the small likelihood that these mothers will receive child support payments from the fathers of their children. Sixty-five percent of absent fathers contribute nothing to their family's upkeep, and only 5.5 percent contribute as much as $5,000 per year.
After presenting this grim picture of the current state of affairs for single parents, the report examines the current CSE system. The report discusses the genesis of the current system, beginning with the 1975 passage of an amendment to the Social Security Act. This amendment required each state to develop its own CSE, or IV-D, program. The amendment was passed, in part, to help offset the costs of the Aid to Families with Dependent Children (AFDC) program. Additional reforms in 1984 and the Family Support Act (FSA) of 1988 strengthened the CSE program. Despite these improvements, the system for assuring that child support orders are enforced is fragmented. The federal Office of Child Support Enforcement (OCSE) provides technical assistance and funding to states to operate IV-D child support programs, but the structure and organization of state CSE agencies vary widely. Some are run by courts, some by counties, and others by state agencies. Thus, the present CSE system involves every branch and level of government, and 54 separate state/territorial systems.
Federal legislative mandates have contributed to increases in the amount of child support payments collected. Total collections in the IV-D program increased from $3.9 billion in 1987 to $7.9 billion in 1992. Paternity establishment also rose during that period from 269,000 in 1987 to 517,000 in 1992. Although this trend is encouraging, much of it is illusory. The increased amounts collected for the IV-D program, for example, are due to the growing number of parents whose child support cases are handled by the government, rather than to any great increase in absent parents who willingly pay child support. In fact, only 26 percent of all women eligible for child support have an award in place and receive the full amount they are due. Over half of all women potentially eligible for child support receive no payment at all.
This situation makes clear that fundamental reforms are needed in the CSE system. The report examines the nature of those reforms. It provides general recommendations for changes in the most pressing areas. For example, the report suggests that CSE be considered a "central element of social policy" for two reasons. One is that a vigorous CSE system will save welfare dollars. However, the most important reason is that children have "a fundamental right to support from both parents".
The report examines the three main reasons for the gap in child support collections: (1) lack of paternity establishment; (2) inadequacy of awards; and (3) lack of enforcement.
First, the lack of paternity establishment makes it impossible to secure child support payments from a child's father. Several barriers to successful paternity establishment exist. Until recently, in most states, the process for establishing paternity did not begin until a mother applied for welfare benefits. Thus, new mothers with no ties to the welfare system had to negotiate the legal system on their own to establish paternity. It is very important for paternity to be established soon after a child's birth. Most new mothers know the name and location of their child's father and are willing to furnish this information. Furthermore, many fathers show a clear desire to acknowledge their relationship to a new baby, but interest often fades as time passes. The Omnibus Budget Reconciliation Act of 1993 requires states to provide in-hospital paternity establishment programs. This should make establishing paternity easier for out-of-wedlock births.
Another problem with the CSE system is that many support awards are inadequate. About 22 percent ($7.1 billion) of the gap between what is currently due and what could be collected is due to low or out-of- date awards. Most support awards are not updated to reflect the noncustodial parent's ability to pay. Despite typical increases in the noncustodial parent's income and the decreasing value of the award with inflation, many awards remain at their original levels. Although the FSA requires that all IV-D orders be updated every three years for AFDC cases and at the request of either parent in non-AFDC cases, many states may have difficulty in complying with the standard, especially states with court- based systems. The report suggests that periodic updating be required for all parents and that automated systems be adopted.
Finally, many support awards are not enforced at all. Only about 69 percent of the child support now is actually paid. Interstate enforcement efforts must be enhanced, especially because, although interstate cases are just as likely to have awards in place, they are less likely to receive payments. The report recommends more and better automation of state systems. It also recommends that the CSE system be simplified and made more uniform nationwide.
The report concludes that, despite these difficulties, the potential for complete collection exists. It speculates that a stronger federal role is needed, perhaps one which utilizes the Internal Revenue Service. In any case, the report concludes that fundamental changes are needed in the way we approach child support enforcement.
This report was prepared by the Working Group on Welfare Reform, Family Support, and Independence. Copies of the report, #5777, are available from the Policy Information Center.
Estimates of the number and distribution of farmworkers in general, and of migrants specifically, vary widely. The estimate for the number of migrant farmworkers ranges from 115,000 to more than 1.5 million migrants and dependents. The children of migrant farmworkers face the difficulties of all children in poverty, compounded by mobility, language, and cultural barriers to obtaining the educational, health, and social services they need.
This report, Services for Migrant Children in the Health, Social Services, and Education Systems, examines successful service integration initiatives for migrant children, and considers research and evaluation efforts for the future.
Six sites were selected for study, based on a variety of factors, including geographic location, programs involved in the service integration effort, ages of the children served, and grower involvement or support. Each site showed good coordination between at least two of the major federal programs serving migrants (Migrant Education, Migrant Head Start, and Migrant Health). The sites selected were: Brockport, New York (Monroe County); Greeley, Colorado (Weld County); Stockton, California (San Joaquin County); Woodburn, Oregon (Marion County); McAllen, Texas (Hidalgo County); and Belle Glade, Florida (Palm Beach and Hendry Counties).
The report examines the service needs of migrant children in education, social services and health. Migrant school children have the lowest high school graduation rates of any population. They are more likely to be below grade level, to have trouble reading, and to lack English fluency. Many migrant children lack continuity in their educations due to frequent mobility. Furthermore, although migrants are likely to be eligible for Medicaid, Aid to Families with Dependent Children (AFDC), and services available through programs such as the Community Services Block Grant (CSBG), none of these funds are earmarked or targeted specifically for the migrant population and the mobility of this group makes access to these services difficult. Research shows that the need for social services, particularly substance abuse and mental health services, is growing. Housing is also a critical need for migrants. Finally, migrant children frequently have health needs that go unmet due to fragmented care caused by their mobility, lack of medical and financial resources, substandard living conditions, language and cultural barriers, and limited health education. Studies show that migrant children are less likely to receive recommended physical and dental check-ups. Chronic health conditions are several times more prevalent in this population, and childhood mortality appears to be 1.6 times higher than that of the entire population.
The multiple service requirements of migrant children indicate a clear need for service integration. The report identifies several factors that facilitate service integration, including: (1) information and resource sharing; (2) holistic and family- centered approaches to case management; and (3) state funding. It also lists the barriers to providing comprehensive services for migrant children. These include: (1) differences in eligibility requirements for programs and in definitions of migrant; and (2) state and local administrative structures. Furthermore, the report describes the most important service needs and gaps across the sites visited. These are: (1) transportation; (2) mental health and substance abuse treatment; and (3) housing.
The report describes a number of models of service integration that were identified during the site visits. Two of the models are systems-oriented approaches. The first involves regional coordination/umbrella organizations. For example, the East Coast Migrant Head Start Project (ECMHSP) provides fiscal and administrative services to Head Start delegate agencies in 12 east coast states. Its goal is to promote continuity of Head Start services to migrant children and their families. It provides program and fiscal monitoring and training and technical assistance at the center level and promotes staff development activities on a regular basis. The model allows sites to serve children and families while the central office takes on administrative tasks such as payroll, purchasing, negotiating for space or resources, and arranging staff training.
The second systems-oriented approach uses community coalitions to assess and plan for the overall needs of their communities. Related efforts in Brockport, New York and Hidalgo County, Texas exemplify this approach. In Brockport, the Coalition of Migrant and Farmworker Services coordinates services delivered by many providers in the area. Service gaps are identified and participants find that this approach works better than dealing with individual providers. The "Working Together Group", an outgrowth of the coalition, meets regularly every two to three months. attempts to break down barriers between providers so that they might better serve the migrant population.
In Hidalgo County, Texas, the "Partners for Self-Sufficiency" is a two-part initiative to address needs in the colonias (rural, undeserved subdivisions where many migrant workers live).. To address the short-term needs of migrants, an intensive case management system links residents to services. For the long-term, the Coalition of Community Service Agencies is a business and community partnership addressing employment, infrastructure, education and training, health care, and human services.
Other, service-oriented, approaches include: (1) forging links between colleges, universities, and other educational institutions (especially medical schools) and the migrant community to access health and education services; (2) in Belle Glade, Florida, the grower, A. Duda and Sons donated the Shannon Center, a Migrant Head Start Center, located on its property; DUDA is also working to establish an after- school tutoring program at the migrant camp and provides space for the migrant health center's mobile van; (3) housing provided by the San Joaquin County, California Housing Authority; (4) interstate coordination efforts developed by the Texas Migrant Council (TMC), the Migrant Head Start grantee and the Texas Migrant Interstate program to provide interstate educational continuity for preschool and older children (grades 7-12), respectively; (5) using promotores, or lay educators, in the colonias of Hidalgo County, Texas to assist with Planned Parenthood and the Expanded Food and Nutrition Program activities; and (6) promoting "one-stop shopping" to help address time and transportation problems.
After describing these exemplary models, the report identifies evaluation issues specific to migrant services, including: (1) measuring baseline service needs and gaps; (2) specifying goals and outcome measures; and (3) following clients over time. It also discusses policy issues and areas for further research.
This report was prepared by the Urban Institute and was sponsored by the Office of the Assistant Secretary for Planning and Evaluation. A summary of the report is available from the Policy Information Center.
As of July 1994, the Health Care Financing Administration (HCFA) reported 136 risk- based health maintenance organizations (HMOs) serving over two million Medicare beneficiaries. HCFA's Office of Managed Care oversees Medicare risk contracts with HMOs. Under a risk contract, Medicare pays an HMO a predetermined monthly amount (capitated rate) per enrolled beneficiary. Medicare beneficiaries are usually required to use HMO physicians and hospitals (lock-in) and to obtain prior approval from their primary care physicians for specialty care.
This report,Beneficiary Perspectives of Medicare Risk HMOs, describes beneficiaries' perspectives about their experiences with Medicare risk-based HMOs. Using a selected, stratified random sample of 4,132 enrollees and disenrollees from 45 Medicare risk HMOs. Information was gathered directly from beneficiaries in 1993, but their responses were not validated through records review or HMO contact.
Most beneficiaries report that Medicare risk HMOs provide adequate service access. They characterize their care as timely, as maintaining or improving their health, and as providing good access to Medicare covered services and to hospital, specialty, and emergency care. Most also found that their HMOs and HMO doctors provided sympathetic care. Furthermore, beneficiaries report that their HMOs adhere to federal enrollment standards for informing them about application procedures, lock-in, and prior approval for specialty care. However, compliance with federal enrollment standards for health screening and informing beneficiaries of their appeal rights appears to be problematic. For example, 43 percent of beneficiaries who could remember said they were asked about their health problems and three percent were required to have a physical examination before enrollment. Twenty-five percent said they did not know about their right to appeal their HMO's refusal to provide or pay for services.
The majority of enrollees also report obtaining appointments to see their primary care physician or a specialist in a timely way. Ninety-four percent of enrollees and 85 percent of disenrollees say they got an appointment within one to two days when they believed they were very sick. Over 75 percent had to wait less than 9 days for appointments with their primary care doctors, and about 66 percent had to wait for the same amount of time to see a specialist. However, 16 percent waited for 13 days or longer for a primary care visit, and 25 percent had to wait this long for a specialty visit. Most beneficiaries wait an hour or less in the office to see their primary care doctors, and most are able to contact their primary doctors by telephone (only 11 percent say they have given up trying to make an appointment because of busy telephone lines).
The majority of enrollees also believe they get the Medicare services they need, but disenrollees report more problems with access to primary and specialty care. Ninety-five percent of enrollees have good access to primary, specialty, hospital, and emergency care. However, 20 to 25 percent of disenrollees say they failed to receive primary care, referrals to specialists, and HMO coverage for emergency care. These perceived access problems and the lock-in provisions of Medicare risk HMOs led 22 percent of disenrollees and 7 percent of enrollees to seek out of plan care.
Moreover, most beneficiaries believe that they are well-treated by their HMOs or primary care doctors. Disenrollees are more likely to perceive unsympathetic behaviors that may restrict access to care. For example, while 12 percent of enrollees feel that their primary care doctors do not take their health complaints seriously, 39 percent of disenrollees feel this way. Over one-third of both groups say this happens all or most of the time. Disenrollees are three times more likely than enrollees to believe that their primary care doctors are more interested in keeping the costs of care down than in providing the best medical care possible.
Finally, disenrollees who have no prior HMO experience are more critical of their experience than disenrollees who have had prior experience; but most join another HMO upon leaving. Disabled and ESRD disenrollees report access problems more often than aged beneficiaries; 66 percent want to leave their HMOs. Eighty-four percent of enrollees want to stay with their HMOs; the remainder either plan to leave or want to leave, but feel they cannot for financial reasons. Of all disenrollments, almost one-third are due to administrative reasons alone, such as a beneficiary's moving or an HMO's clerical error. The remaining two-thirds of disenrollees voice more criticism regarding their awareness of their appeal rights, the effectiveness of HMO care and access to services.
Although most beneficiaries are satisfied with the care they receive under Medicare risk HMOs, the survey results indicate some serious problems with enrollment procedures and service access. The report recommends that HCFA pay immediate attention to the following problem areas: (1) better informing of beneficiaries about their appeal rights as required by federal standards; (2) careful examination of service access problems reported by disabled/ESRD beneficiaries; and (3) monitoring HMOs for inappropriate screening of prospective enrollees at the time of application. Other issues which warrant examination are beneficiaries perceptions of (1) making routine appointments; (2) declining health caused by HMO care; and (3) HMOs' refusal to provide certain services.
This report was prepared by the Office of Inspector General. Copies of the Executive Summary, #5824, are available from the Policy Information Center.
State governments have been involved in supporting the education and training of health professionals for almost 50 years. Many states provide loan and scholarship programs for medical students and physicians in training. Many have established health service corps loan programs or similar loan and scholarship programs to help create a cadre of physicians who will practice in underserved areas for a specific time period.
Despite these efforts, states remain concerned about the lack of generalist physicians in their rural and inner city areas. Many have been redesigning their incentive programs in the hope that these changes will make a difference. More focused, coordinated programs are being developed in state governments than ever before. This report, Review of State Legislation Related to Increasing the Training, Supply, Recruitment, and Retention of Generalist Physicians 1985-1991,examines these state efforts.
State legislative strategies between 1985 and 1991 focused on five areas: (1) planning and oversight; (2) building primary care teaching capacity; (3) student and resident loans and scholarships; (4) enhancing the practice environment; and (5) reducing licensing and malpractice barriers. Between 1985 and 1992, 47 states enacted 238 laws intended to improve generalist physician supply and distribution. Most of these laws were passed during the latter part of the period: in 1985, seven states enacted laws, and three did so in 1986, in contrast to the 23 states who did so in 1991 and the 25 who did so in 1992. States use a variety of approaches to address the physician shortage and distribution problems. During this period, six states created legislation addressing all five strategies given above, and another 12 enacted legislation in four areas. State attention focuses on training and educational programs and on loan or scholarship programs. Many states are also developing more coordinated efforts to deal with physician workforce issues. Many new state office of rural health have been vested with administrative, planning, coordination, financing, and oversight responsibilities. Several states have also implemented coordinated programs to recruit and retain physicians, and a few have established information clearinghouses for information on health workforce needs and supply and on referral and placement services.
Many states have also concentrated on medical student education and resident training. Some, such as Alabama, Texas, and West Virginia have incorporated rural or family practice into the curriculum. Others have changed residency training by developing or expanding family practice programs. New York weights graduate medical education funding to favor generalist physician training, while Alabama and West Virginia have emphasized the importance of building preceptor or training sites in rural or underserved areas.
However, the most common strategy states use to address health professional shortages is still to offer financial incentives to students. Scholarship and loan programs are being examined to determine whether they can be redesigned to direct more students into family practice. Some programs now include additional requirements linking assistance to specific services, while others have begun to implement scholarship and loan programs for health professionals other than physicians. Furthermore, greater attention is being paid to developing cooperative educational programs for physicians and other health professionals at the undergraduate, post-graduate, and continuing education levels.
States also use other financial incentives to promote better physician distribution. These incentives are primarily financial, either granting some sort of income supplement to providers or reducing potential risks and obligations related to malpractice.
Finally, a limited number of states have attempted to enhance the practice environment in underserved areas. A few have modified licensing and regulatory requirements to allow retired physicians or physicians trained overseas to practice in these areas; some have also provided assistance to rural hospitals that might need special licensing provisions. Some have formed networks of rural hospitals or linkages between health care extension sites and physician offices. Other states have improved opportunities for continuing education by supporting telecommunications networks and the availability of temporary physician substitutes.
Despite this flurry of activity, enacted legislation does not always translate into action or results. The primary reasons for this are: (1) fiscal constraints; (2) the relative novelty of many programs; and (3) limited information on practice decisions and retention rates.
The report gives composite descriptions of the legislative initiatives for the period 1985 to 1991 according to five major subject areas: (1) planning and oversight bodies; (2) institutional incentives; (3) financial incentives for students and residents; (4) incentives to enhance the practice environment; and (5) licensure, risk management, and legal issues. The report also provides state-by-state profiles of legislative initiatives.
The report concludes by stressing that initiatives must (1) include the means to evaluate and enforce their short- and long- term effectiveness; (2) begin earlier in the training pipeline; (3) make better use of the existing provider supply by improving the practice environment for generalists; and (4) be supported with much greater funding and attention from policymakers if they are effective.
This report was prepared by the Intergovernmental Health Policy Project at the George Washington University, and was sponsored by the Health Resources and Services Administration. The report's project officer, Debbie Jackson, may be reached at (301) 443-6326 . Copies of the Executive Summary, #5828, are available from the Policy Information Center.
The Simulation of Trends in Employment, Welfare, and Related Dynamics (STEWARD) model was developed to inform the debate on welfare policy by simulating policy options that reflect questions of encouraging work over welfare, reducing the duration of welfare receipt, and changing costs and caseloads.
This report, Simulation of Trends in Employment, Welfare, and Related Dynamics (STEWARD), discusses the simulation process, design challenges, the concept of the model and assumptions about the economic behavior of families, how these assumptions are translated into a working model, the sources of key empirical estimates, the impact measures routinely presented in the model output tables, and the model database (including adjustments).
The STEWARD model operates on a database that combines information from household surveys that have tracked the work and welfare behavior of low-income families for several years. STEWARD uses this information to simulate the decisions made over a four-year period by a sample of female heads of families to enter or leave welfare, and, if they work, to do so part-time or full-time. Each simulation creates work and welfare histories for a representative sample of these women under a specified policy scenario.
STEWARD performs three kinds of simulations: (1) a baseline simulation defined as Aid to Families with Dependent Children (AFDC) and Food Stamp Program (FSP) caseloads and dynamics under the policies observed last year; (2) a current services simulation representing AFDC and FSP outcomes after recently enacted policies are fully implemented; and (3) simulations of AFDC and FSP outcomes under welfare reform options on top of current services policies. The differences in the outcomes of the current and reformed policy scenarios represents the net effect of changes caused by reform.
The report describes the conceptual design of the model, including a brief overview of the research which made its development possible. It states that three key objectives influenced the conceptual design of STEWARD: (1) to include multiple work and welfare participation decisions in the model; (2) to use structural parameters to simulate responses to policy changes; and (3) to enable individuals to change their work and welfare participation decisions. The report also describes the key components of the model. The central mathematical structure of STEWARD is characterized by a set of ten equations. The first six constitute a model of individual labor supply behavior, while the last four constitute a model of individual welfare transitions. Individuals are assumed to choose from five labor supply decisions and three welfare program participation options each month. Thus, there are fifteen possible outcomes for each individual every month. Eight additional equations are included in the model.. While these are not essential to its structure, they are important components of the simulation of labor supply and welfare participation behavior. They address the costs and benefits of employment (indicated by the hourly wage, child care costs, and the probability of health insurance coverage), and outcomes related to the payment of child support by noncustodial fathers of the children in the sample.
The report next addresses the operational structure of STEWARD. It reviews some of the key individual and family characteristics to be included; how the model constructs employment-related characteristics, including earnings, child support payments, child care costs, and taxes; how the model controls for Medicaid and private health insurance benefits; child support reforms; the treatment of AFDC and FSP benefits; and other topics.
The report also describes the database used by the model, provides an overview of the model implementation, and describes each piece of the model software and its installation, and summarizes the process of running STEWARD simulations.
The report contains appendices giving information on the derivation of sample weight adjustments, the contents of the model input database, and a listing of STEWARD's computer code.
This report was prepared by Mathematica Policy Research, and was sponsored by the Office of the Assistant Secretary for Planning and Evaluation. The report's project officer, Don Oellerich, may be reached at (202) 690-7507. Copies of the Introduction and Overview of the STEWARD model are available from the Policy Information Center.
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