In This Issue:
- The Well-Being of Children and Youth
- Taking Place Differences into Account in Welfare to Work Programs
- Health Care Costs of Domestic Violence
- Long-Term Care in Home and Community-Based Settings
- Private Sector Health Care Organizations and Public Health
TRENDS IN THE WELL-BEING OF AMERICA'S CHILDREN AND YOUTH: 1996
The report, Trends in the Well-Being of America's Children and Youth: 1996, is the first annual report from the Department of Health and Human Services (HHS) to present the most recent, most reliable data on five key areas in the lives of children and youth. These areas are: population, family, and neighborhood; economic security; health conditions and health care; social development, behavioral health, and teen fertility; and education and achievement.
The report contains two sections. The first is a "quick reference guide" describing national trends for seventy-four indicators of child and youth well-being. All of these indicators are based on data collected by the federal government. For each indicator, tables and graphics illustrating trends are given, accompanied by a narrative describing the most pertinent features of the data. The second section contains a review of trends in the socio-demographic characteristics of children, youth, and their families. The section emphasizes historical trends, treating long-term shifts that in some cases cover two centuries.
On the whole, the quick reference guide presents data from the 1970s to the 1990s although some data are presented for periods prior to the 1970s , as are some projections into the 21st century. The report shows that the number of children under age eighteen has varied widely: between 1950 and 1960, the number of children increased from 47.3 to 64.2 million, then rose to 69.6 million in 1970, and fell to 63.7 million in 1980. It is projected that the number of children will rise to 73.6 million by the year 2010. The report also presents data on children as a percentage of the population. For example, in 1950, children constituted 31 percent of the population; by 1960, the proportion had increased to 36 percent. However, by 1990, children constituted only 26 percent of the population. As well as presenting data for the population as a whole, the report gives information on the racial and ethnic composition of U.S. children and on immigrant children.
Data on economic security is also presented, including charts on trends in mean family incomes, children in poverty, child support nonpayment, the impact of cash and near-cash transfer programs on poverty, and welfare receipt and dependence. Another section of the report presents data on health conditions (such as infant and child mortality, teen motor vehicle accident, homicide, and suicide deaths, general health conditions, and abuse or neglect). It also examines health care for children, including data on health insurance coverage, prenatal care, and immunization. The social development and behavioral health of all children and fertility of teenagers are also represented in the data, as are education and achievement.
There are both positive and negative trends reported. On the positive side, the rate of full immunization for two-year-olds has increased while the infant mortality rate continues to decline. Teen births for those aged fifteen to nineteen declined between 1991 and 1993, although the teen birth rate is still higher than it was twenty years ago. In education, mathematics and science proficiency has increased, while the proportion of children who watch six or more hours of television a day has decreased. However, negative trends are also apparent. For example, the mortality rate for minority youth has increased, as has the proportion of children living in single-parent households. The poverty rate for children and youth has increased and the rate of children living in extreme poverty has increased dramatically. Finally, for many indicators of well-being, minority children and youth fare much worse than their white counterparts.
The second part of the report traces changes in the socio-demographic characteristics of children, youth, and their families over a long historical period. In some cases, it goes back to the first Census of the United States, taken in 1790. The section, titled "Population Change and the Family Environment of Children," discusses demographic issues such as population size and composition, the geographic distribution of the population, marriage and divorce, childbearing and family size, life expectancy and mortality, and household size and composition. The report notes that, over the past 150 years, there have been major changes in several areas that directly affect children's lives. The revolutionary shift to non-farm work by fathers, the dramatic reduction in the size of the average family, and great increases in the average level of schooling have all affected children's family environment. More recently, increases in mothers' labor force participation, and in mother-child families with no father present in the home have also contributed to vast changes in children's life situations. The report maintains that:
a fundamental cause driving these seemingly disparate changes was the desire of parents to improve, maintain, or regain their relative social and economic status compared with other families, when confronted with changing and often uncertain, difficult, or precarious social and economic conditions. (pg. 251)
Finally, the report discusses using children as the unit of statistical analysis. It notes that, although it may seem apparent that research on children should be conducted in this way, until recently most studies have used parents, adults, or families as the units of statistical analysis. The report suggests that existing databases, such as censuses, registration systems, and surveys, should be re-analyzed using children as the unit of statistical analysis. One effort to do so is the Bureau of the Census's planned annual Survey of Program Dynamics (SPD). Data from this and other efforts will help to inform public policy debate on welfare and health care reform, as well as other areas of public interest.
This report was sponsored by the Office of the Assistant Secretary for Planning and Evaluation. Section I was produced under contract by Child Trends, Inc. Section II was written by Donald J. Hernandez of the United States Bureau of the Census. The report's project officer, Matt Stagner, may be reached at (202) 690-5653. Copies of the report's executive summary only (PIC ID No. 6170) are available from the PIC. Copies of the full report are available from the Government Printing Office (stock number 017-022-01336-6) at a cost of $26.00. Call (202) 512-1803.
WELFARE TO WORK: THE NEED TO TAKE PLACE DIFFERENCES INTO ACCOUNT
Most health and social services programs tend to concentrate on policy analysis that considers impacts on individuals, families, and households. In contrast, economic development and labor market policy analysis focuses on places and variations among places. This report, Welfare to Work: The Need to Take Place Differences Into Account, uses this second approach to consider the ability to move from welfare to work within the context of variations in geographic areas. It attempts to determine whether differences in place affect the ability of individuals to move from welfare to work and the implications for policy and legislation, technical assistance, and research and evaluation.
The report shows that research has found a correlation between geographic location and the ability of an individual to move from welfare to work. Differences exist among regions and states, between metropolitan and non-metropolitan areas, and between central cities and suburbs. For example, a 1983 study found that welfare exits due to an increase in employment earnings were more likely in the South and East than in the West and North Central regions. Other data show that variation in welfare to work exits is substantial: although the mean rate of average monthly exits from Aid to Families with Dependent Children (AFDC) as a percentage of average monthly caseload is 5.53 percent, in South Dakota it is 12.62 percent and in Washington state it is 3.45 percent. A 1995 study shows that, controlling for a number of personal variables, the probability of exiting from welfare within a two year time period is considerably lower for a welfare family living in a large metropolitan area than it would be for the same family living elsewhere. Similarly, studies show that variation in the ability to exit welfare for work exist among metropolitan areas; for example, 1994 average monthly exits from welfare due to earnings as a percentage of average monthly caseload was three times greater in the rest of New York state than in New York City.
The report focuses on variations among metropolitan statistical areas (MSAs), since these areas contain most of the U.S. population and since they can be considered functional labor markets.
There are differences among MSAs in the demand for low-skilled labor and in the employment skills of welfare recipients and their willingness to work. For example, it should be easier to move from welfare to work in areas where the unemployment rate is low and employers are seeking workers, in areas that are experiencing growth in relatively low-skilled jobs and where there are substantial vacancies from these types of jobs. Empirical evidence suggests that this is the case. On the supply side, it should be more difficult for a welfare recipient to find work in areas where there are a large number of other people with similar skills looking for work. Furthermore, welfare recipients in one area may have better job-related or cognitive skills, job readiness, or motivation than those in other areas. Variations in local wage rates will also affect welfare to work exits. People are more likely to move into work where wage rates are high.
Other characteristics also cause variation in the rate of welfare to work exits. For example, on the state level, policies on eligibility, income disregards, child care, public service or community service jobs, and benefit levels will affect the ability of welfare recipients to find work. Furthermore, differences in the characteristics of welfare recipients (such as length of welfare receipt, health problems, and substance abuse) also form barriers to employment. The local institutions in place to serve and assist welfare recipients, such as local welfare, employment and training, and employment agencies, vocational schools, community colleges, and local economic development agencies, also have an impact on welfare recipients' ability to find employment.
The report finds that, since place differences cause variations in the ability to move welfare recipients into work, federal and state policies should factor them into any performance standards they set for welfare-to-work programs. Furthermore, greater attention must be given to how program design effects performance at the local level. Thus, local programs should be flexible enough to use the most effective design, whether it is based on a labor force attachment model or on a human capital development model.
Finally, the report concludes with the observation that much of the place differences in the ability of welfare recipients to find work may be caused by insufficient demand for low-skilled workers in any given area. Thus, some demand side response (such as wage subsidies to private employers or the creation of community service jobs) may be in order. Furthermore, just as programs themselves must take into account place differences, so should evaluation efforts be sensitive to them. An important aim of research and evaluation, then, should be to identify characteristics of areas in order to determine the appropriateness of program designs.
This report was sponsored by the Office of the Assistant Secretary for Planning and Evaluation and was written by Hal Wolman, Ph.D. Copies of the report, PIC ID No. 6133, are available from the Policy Information Center.
THE COST OF DOMESTIC VIOLENCE TO THE HEALTH CARE SYSTEM
Domestic violence, also referred to as intimate partner violence, is costly to both its victims and to society as a whole. Victims of such violence have more physical health problems, higher utilization of health care services, higher levels of depression, drug and alcohol abuse, and suicide attempts than non-abused women. Costs to the health care, social services, and criminal justice systems, as well as costs associated with lost productivity and premature death are high, but are difficult to quantify.
The report, The Cost of Domestic Violence to the Health Care System, reviews the literature on the prevalence, incidence, and cost of domestic violence; examines data pertaining to its mental health consequences, and develops an economic model to determine the cost of domestic violence to the health care system.
The prevalence of domestic violence was examined by looking at various data sources: national surveys on family violence; studies based on national crime surveys; studies based on small samples from one hospital or community; and studies focusing on domestic violence during pregnancy. These studies, which differ in size, representativeness, and type of abuse, produced a wide range of prevalence estimates. However, studies consistently find that millions of women are abused by their partners or former partners each year. For example:
- The Commonwealth Fund's 1993 Survey of Women's Health found that 7 percent of women who were married or cohabiting were physically abused, and 37 percent were verbally or emotionally abused by their spouse or partner.
- A 1995 survey conducted by Plichta and Weissman found that 8.4 percent of married or cohabiting women had been physically abused by their partners in the previous year.
- The National Crime Victimization Survey conducted by the U.S. Department of Justice reports that 5.4 women per 1,000 are victimized by an intimate acquaintance.
All data sources are subject to limitations that may result in underreporting of prevalence. All estimates come from self-survey reports which exclude persons not at home when interviewers call; women who are unwilling to answer the telephone or door; non-English speakers; military families living on base; and homeless, hospitalized, institutionalized, or incarcerated individuals.
Despite growing attention to the toll that domestic violence takes, documentation of its costs is limited. Only three studies were found that provide estimates of the economic burden imposed by domestic violence. These estimates range from $1.7 billion in total costs annually, to between $5 and $10 billion annually for losses due to domestic violence, to $67 billion each year. The first two estimates have been criticized as seriously underestimating the costs of domestic violence, the last includes nonmonetary losses such as pain, suffering, and lost quality of life totaling $58 billion.
Abused women suffer both physical and mental health consequences. However, data documenting the type of injuries suffered and their associated costs are currently lacking. Data limitations are particularly evident in the area of mental disorders associated with domestic violence, as available estimates of the prevalence of domestic violence related mental health disorders vary greatly. This report includes a section on these data and the difficulty in interpreting them. For example:
- Literature reviewed by the report finds that victims suffer greater rates of depression. Estimates range from 15 to 83 percent for abused women compared to 10 to 21 percent among the general population of women.
- Battered women also have higher rates of alcohol and drug abuse -- estimated rates of alcohol abuse and dependence among battered women range from 15 to 29 percent, compared to lifetime prevalence rates of 5 to 8 percent in the general population. Rates of drug abuse and dependence range from 7 to 25 percent in abused women, compared to lifetime prevalence rates of 5 to 6 percent in the general population.
- Battered women also exhibit much higher rates of post-traumatic stress disorder (PTSD) and suicide ideation and attempts but, again, the estimated rates vary greatly.
After discussing the prevalence and incidence of domestic violence, as well as its mental health consequences, the report presents an economic model to determine the costs of such violence. These costs represent the monetary burden to society of illness, lost productivity, mental health consequences, social and criminal justice system services, and premature death resulting from domestic violence. These costs are typically divided into two categories: direct costs and indirect costs. The first category includes the actual dollar expenditures involved. Indirect costs consist of morbidity and mortality costs, such as reduced or lost productivity and lost output due to premature death. The cost of domestic violence would be estimated as the product of prevalence (the number of cases for the year) and the cost per case. The report then discusses possible data sources (including new sources) that should be used in the model. It also gives a detailed discussion of the model's application.
This methodology study represents the first step in documenting the total cost of domestic violence to the United States. A future study will apply the cost model to the prevalence data and assign actual monetary costs. This next study is expected to become the basis of a report to Congress that will also discuss ways in which the prevalence and cost of domestic violence may be reduced.
This report was sponsored by the Office of the Assistant Secretary for Planning and Evaluation and was prepared by Dorothy Rice, Wendy Max, et al., at the Institute for Health and Aging at the University of California, San Francisco. School of Nursing. The study's project officer, Sandra Howard, may be reached at (202) 690-7778. Copies of the executive summary, PIC ID No. 4528, are available from the Policy Information Center.
BEST AT HOME: ASSURING QUALITY LONG-TERM CARE IN HOME AND COMMUNITY-BASED SETTINGS
More than 10 million Americans of all ages need long-term care (LTC) if they are to remain in their own homes or in community-based care. Slightly more than half of these individuals are aged 65 or older; two-fifths of the remainder are working age adults. Between 18,000 and 65,000 residential care settings serve one million residents. Each year, billions of dollars are paid for LTC through a variety of funding sources, including more than 100 federal programs. The major federal programs providing such care are Medicare, Medicaid, Social Security Disability Insurance, and state programs. Health care reform will undoubtedly affect both funding and provision of these services.
The report, Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings, examines the quality of care provided in LTC clients' homes, whether those homes are apartments in residential care facilities, a room in an adult child's home, or a single family dwelling. It considers how quality of care is assured and improved, and presents a study plan for a more thorough examination of these issues.
Quality assurance seeks to prevent, detect, and correct problems in the quality of services provided, while quality improvement attempts to raise levels of quality through continuous study and modification of services. The report discusses the recent shift in quality assurance and improvement to outcomes measurement. That is, although structure and process measures are still considered important, government regulators now stress the importance of ensuring that a regulated long-term care provider achieves a desired goal, instead of simply meeting basic capacity standards and procedural steps that should lead to the achievement of stated goals. Moreover, the report notes the need for both external and internal quality assurance programs that measure outcomes. External programs are implemented by outside agencies and entities like government or accreditation organizations, and generally involve regulation (licensure, certification, and accreditation; or inspection and audit functions). They tend to focus on correcting poor performance. Internal programs are developed by provider organizations to improve their programs and performance. Many of these programs use the principles of "total quality management" and "continuous quality improvement". Internal procedures and information systems, ongoing data analysis, staffing policies, case management and consumer feedback mechanisms are used by providers to assist them in delivering high-quality, responsive, and continually improving care.
The report considers the appropriateness, effectiveness, and adequacy of LTC quality assurance and improvement strategies. It notes the difficulties inherent in determining the appropriateness of programs, such as uncertainty about what constitutes "quality" in programs that offer services that are much more comprehensive that other medical care, differing perspectives on quality held by consumers and providers of services; and the diversity of the population receiving services. The effectiveness of LTC quality assurance and improvement programs can also be difficult to measure. While some studies indicate that states with more extensive regulation of LTC have better quality measured in several different areas, there is little evidence that using professional credentialing and minimum training standards as guarantors of quality is effective. LTC clients are usually more concerned with the characteristics of their providers (such as honesty and reliability) than with credentials like degrees or training certificates. The report also notes that most external regulatory programs focus on those providers who give extremely bad service. However, the extent to which such programs are effective in removing bad practitioners is uneven; complaint resolution mechanisms may also be ineffective. The most important issue, however, is that external quality assurance programs do not have the goal of steadily improving quality over time. In determining the adequacy of quality assurance and improvement efforts, the report notes a fundamental problem in that LTC is provided in isolated settings where peer and public oversight is almost nonexistent.
The report concludes with a proposed plan to study quality in board and care and LTC settings. Six major areas are included in the plan. Key questions are: (1) the key features of home care services and clients, compared to key features of residential care settings and clients; (2) the type, frequency, and severity of quality problems in home care and residential care; (3) factors enhancing or impeding the provision of quality care in these settings; (4) ways in which quality assurance and improvement can be made appropriate, effective, and adequate; (5) the role consumers and their caregivers should play in defining and evaluating quality; and (6) the possibility of national minimum or model standards to ensure quality of care. The report proposes an 18-month-long study to examine these issues.
This report was sponsored by the Administration on Aging and was prepared by the Institute of Medicine. Copies of the executive summary, PIC ID No. 6214, are available from the Policy Information Center.
PRIVATE SECTOR HEALTH CARE ORGANIZATIONS AND PUBLIC HEALTH: POTENTIAL EFFECTS ON THE PRACTICE OF LOCAL PUBLIC HEALTH
Recently, a convergence of public and private health care goals and objectives has begun a move towards increasing partnership on both sides. An Institute of Medicine study, The Future of Public Health, urged that public health agencies focus on three core functions: assessment, policy development, and assurance, rather than on service delivery. In the private sector, health care industry restructuring is causing an increased interest in public health models. The emergence of consolidated and integrated health care systems and of managed care models has spurred this interest.
This report, Private Sector Health Care Organizations and Public Health: Potential Effects on the Practice of Local Public Health, examines the emerging role of private health care providers in delivering public health services. It takes as its conceptual framework the IOM model of three core public health functions, and the Public Health Service (PHS) elaboration of these functions into ten essential public health services. The study identifies and presents case studies of private health care organizations providing these ten essential public health services.
The study synthesizes findings from site visits to health systems and managed care organizations that were identified as being active in public health and population-based activities in their communities. A review of literature and key informants from the health care industry identified 23 organizations that were mentioned by at least two different sources. Eight geographically diverse health systems or managed care organizations were selected for case study.
The report finds that, while most private sector activities fall into the essential public health services (EPHS) within the "assurance" core function, private organizations are assuming active roles in all three core public health functions. For example, in the "assessment" function, private organizations conduct neighborhood-focussed assessments that identify service needs or that support targeted screening or health promotion activities. They also perform global, diffuse, community-wide assessments that attempt to address root causes of community issues that might affect health, such as housing, education, and child care. In the area of "policy development", the health systems and managed care organizations engage in efforts to improve public information, promote health, mobilize communities, and build coalitions. Some of these efforts address the entire community, while others focus on specific neighborhoods or populations. The case study organizations are active in both city-wide and neighborhood coalitions, and are especially key players in the former, since they have the community standing and visibility to engage most important stakeholders in their communities. Within "assurance", even though oversight functions so essential to assurance cannot be carried out by private organizations, much service delivery related to public health and prevention has been turned over to them. In some sites, all service delivery activities are coordinated as part of a single comprehensive effort; in half of the organizations, these service delivery activities are a collection of stand-alone programs addressing target populations that are not necessarily part of the organization's cachement area. In some organizations, multiple programs addressing the same populations are underway.
Almost 40 percent of the public health activities of private organizations are carried out by the organization alone. Community-based organizations and other health care providers are the most common outside collaborators. In communities with strong and visible public health departments, the organizations are likely to work closely with them. However, this is the case in only half of the case study organizations. In the other half, the private organizations had either no relationship with the local health department or a poor one.
There are many factors that may motivate private organizations to take on public health functions. While the increasing role of managed care might have been expected to lead to a convergence of prevention strategies and business strategies, in fact the study finds that altruistic motivations such as a desire to benefit communities and to fulfill an organizational mission predominate. While about one-quarter of activities were motivated by business-related causes (including building visibility and networks, fulfilling marketing objectives, increasing revenue and customers, and meeting quality assurance requirements), 68 percent had altruistic motivations. Most of these activities are based in corporate offices or a separate unit of the organization, rather than in a hospital service or clinic.
Although the study praises private efforts rooted in altruism, it cautions that the separation of these activities from an organization's operating structure and business strategy may mean that they are eliminated in an era in which private health care organizations are increasingly pressured by the bottom line. The lack of connection between these public health and prevention activities and the host organization's business strategy may be attributed to the slow pace of health care reform, active corporate restructuring, and market fragmentation. The study indicates several external "levers" that may move private sector health care organizations to integrate public health and prevention approaches into corporate strategy, including purchaser pressure, quality assurance "report cards", and community benefit standards. In addition, the study highlights some ways in which government can "level the playing field" so that organizations are not penalized competitively for offering public health and prevention activities, including mandating these services in government health insurance contracts, other benefit mandates, and reform of ERISA.
This report was sponsored by the Centers for Disease Control and Prevention and was prepared by Macro International, Inc. The study's project officer, Nancy Cheal, may be contacted at 404-639-7095. Copies of the Executive Summary, PIC ID No. 6213, are available from the Policy Information Center.
Recently Acquired Reports
- Impact of Ryan White CARE Act Title I on Capacity Building in Latino Community-Based Organizations (PIC ID No. 6197)
- Interstate Compact on Adoption and Medical Assistance (PIC ID No. 6183)
- Limited English Proficiency as a Barrier to Health and Social Services(PIC ID No. 6192)
- Evaluation of Health Needs of Newly Arriving Refugees (PIC ID No. 6199)
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, which is updated daily, provides project descriptions of these studies. The on-line database is now accessible via the Internet on the HHS HomePage. Inquiries regarding PIC services should be directed to PIC Central Mailbox, or to (202) 690-6445