Performance Improvement 1998. Office of the Assistant Secretary for Planning and Evaluation

02/01/1998

OFFICE OF THE ASSISTANT SECRETARY FOR PLANNING AND EVALUATION

MISSION: To provide analytical support and advice to the Secretary on policy development and assist the Secretary with the development and coordination of departmentwide program planning and evaluation activities.

Evaluation Program

  • The Assistant Secretary for Planning and Evaluation (ASPE) functions as a principal advisor to the Secretary on policy development and, in this capacity, conducts a variety of evaluation and policy research studies on issues of national importance. ASPE also is responsible for departmentwide coordination of legislative, planning, and evaluation activities. In its evaluation coordination role, ASPE has the following tasks:
  • Provide annual guidance to all HHS agencies and staff offices regarding evaluation priorities, procedures, and review requirements.
  • Review evaluation priorities proposed by HHS agencies, providing advice about the focus or method of proposed projects and identifying opportunities for collaboration, and effective use of resources.
  • Prepare planning and summary reports on evaluation activities as required by Congress.

Through the departmental evaluation planning process, ASPE has the capacity to identify crosscutting program or policy issues of particular concern to the Secretary and specific program and policy areas not covered by the HHS Agency evaluation plans. In these instances, ASPE initiates evaluations or collaborates with the agencies to conduct evaluations or policy assessments. For example, in recent years, ASPE has initiated projects to develop cost estimates for health financing issues in general, and specifically for the Medicare and Medicaid programs; the effects of managed care expansion on public health infrastructure; welfare-to-work approaches; long-term care alternatives; and studies evaluating alternative services for children at risk of harm from drug abuse, crime, child abuse, and other pathologies.

Another continuing evaluation objective of ASPE is to support and promote the development and improvement of data bases that HHS agencies and ASPE use to evaluate health care programs and health trends. For example, ASPE has been the major initiator in collaboration with the National Center for Health Statistics at the Centers for Disease Control and Prevention of the first comprehensive survey of people with disabilities in the United States. The first component of these new data was completed in FY 1996, and national prevalence data on disability are now available. The ASPE co-chairs and provides support to the HHS Data Council, which is charged with integrating key national surveys, such as linking health status indicators with indicators of well-being. The Department needs more comprehensive data sources to assess anticipated transformations in health and human services.

Finally, ASPE uses evaluation funds to promote effective use of evaluation-generated information in program management and policymaking. The latter is accomplished through the dissemination of evaluation findings and other activities, such as providing technical assistance to agencies in the development of performance measures.

Summary of Fiscal Year 1997 Evaluations

During FY 1997, ASPE completed a wide range of studies and reports on many issues, providing information useful to the Secretary and the HHS divisions for program planning and budget and legislative development.

Health Policy

Market Barriers to the Development of Pharmacotherapies for the Treatment of Cocaine Abuse and Addiction Final Report (6694) presents an analysis of the market barriers to development of pharmacotherapies for substance abuse and addiction, particularly for abuse of and addiction to cocaine. The study examined the development of pharmacotherapies for cocaine abusers in light of the size of the potential market, market penetration estimates, and the basic relationships between price, market size, and revenues. The report outlines several critical market barriers that must be taken into account. The substance abuse treatment market relies heavily on State and Federal reimbursement. Most substance abuse treatment services are subsumed under the mental health benefits of entitlement programs, and drug companies are reluctant to rely upon this kind of reimbursement in an age of shrinking budgets for mental health services.

Public Health Laboratories and Health Systems Change (6458) explored how the relationships among public health laboratories, managed care organizations, and other stakeholders in the laboratory services market have recently changed and the implications of these changes for Federal and State governments. The dynamic health care environment is posing many new challenges for public health laboratories. Changes in both the public and private sectors have made it increasingly difficult for public health laboratories to fulfill their mission. In the private sector, managed care and independent laboratories are expanding; hospital-based laboratories are consolidating; and private sector laboratories are experiencing rapid technological change, both in a clinical sense and in information processing. In the public sector, public health laboratories are experiencing a redefinition of the public health safety net, with greater reliance on managed care to address public health needs and shrinking budgets as State coffers have decreased.

Assessment of Performance Measures for Public Health, Substance Abuse, and Mental Health (6177). ASPE formed the Panel on Performance Measures and Data for Public Health Performance Partnership Grants (PPGs) to examine the state-of-the-art in performance measurement for public health and to recommend measures that could be used to monitor the PPG agreements to be negotiated between each State and the Federal Government. Performance measures were identified in ten public health areas: chronic diseases, sexually transmitted diseases (STDs), human immunodeficiency virus (HIV) infection, tuberculosis (TB), mental health, immunization, substance abuse, sexual assault, disabilities, and emergency medical services. More than 3,200 measures were proposed to the panel through various outreach efforts. The panel used the following four guidelines to assess the measures: (1) the measure should be specific and result oriented; (2) the measure should be meaningful and understandable; (3) data should be adequate to support the measure; and (4) the measure should be valid, reliable, and responsive. The panel found that many Federal efforts to collect health-related data provide national rates, but many do not collect data that provide State-level rates, and that much State-level data may not be comparable.

Information Needs Associated with the Changing Organization and Delivery of Health Care: Summary of Perceptions, Activities, Key Gaps, and Priorities (6388) reports on unmet needs for supply-side information (information provided by health care suppliers and insurers) on the health system, focusing on helping HHS identify how information needs associated with a changing health care system are perceived by a wide variety of user groups and constituencies. Based on information gathered from over 50 individuals and from a review of relevant literature and Web sites, the report examines perceived gaps, their causes, and the activities generated in response to those perceptions. The report identifies 23 ongoing efforts within the private sector, States, and foundations to address these gaps, and studies 11 of these more thoroughly. The study concludes that private sector stakeholders and States cannot alone sufficiently address supply-side information needs, giving importance to Federal leadership and convening functions.

State Regulatory Experience with Provider-Sponsored Organizations: Final Report (6628) describes the experience of selected State governments in regulating provider-owned health care delivery systems that accept insurance risk for the provision or arrangement of health care services (provider-sponsored organizations, or PSOs). The States included in the study are California, Colorado, Illinois, Iowa, Minnesota, Ohio, Pennsylvania, Texas, and Washington. The report finds that the two models that States use to regulate the activities of PSOs contracting directly with purchasers of health care (e.g., employers) are (1) licensing the organizations as they would a nonprovider-owned entity, and (2) creating a separate licensing category for risk-assuming PSOs. The study found that the States vary considerably in their regulation of PSOs that assume risk from self-funded, ERISA-exempt employer plans, and concludes that since State policy toward PSOs is still in the early stages of development, the lessons to be learned by Federal policymakers are limited.

Establishing an Analytical Framework for Measuring the Role of Reinsurance in the Health Insurance Market (6573). Reinsurance is widely used by underwriters of health benefits to limit their risk exposure. Reinsurance contracts can be structured in many ways, and insurers can use reinsurance to limit their risk for an individual contract or exposure, for a group of contracts or exposures, or for a whole portion of the insurer's business. This report presents a limited analytical study of the level of risk borne by reinsurers in three markets: the indemnity insurance market, the managed care market, and the self-insured employer benefit plan market. The purpose of the study is to determine to what extent these data can be used to measure the role of reinsurance in the various markets and to suggest ways whereby better assessments of reinsurance might be made. The report was generally unable to identify either data sources or existing research allowing quantification of the risk being ceded to reinsurers in the three markets. While a substantial amount of information is available about reinsurance in indemnity (non-HMO) health insurers, the data are aggregated in ways that make it difficult to specifically identify transactions related to primary health insurance offered to groups and individuals.

A Framework for Assessing Insurer Responses to Health Care Market Changes (6572). Where once a few large commercial carriers dominated the market with fee-for-service plans, there are now dozens of plans in most markets. In highly competitive markets, plans and carriers develop more sophisticated strategies and arrangements to identify and retain target markets. To better

integrate government programs and develop public policy, the variations and rationales for insurers' business strategies need to be better understood. This project developed an analytical framework for analyzing insurer behavior, responses to insurance market reforms, and the likely impact of insurer behavior on the availability and cost of insurance.

Deriving State-Level Estimates From Three National Surveys: A Statistical Assessment and State Tabulations (6380). HHS programs are rapidly changing their focus from the national to the State level. Federal roles and responsibilities traditionally played by HHS will be dramatically altered. Recent events bear this out. Landmark legislation eliminating entitlement to Aid to Families with Dependent Children (AFDC) benefits and block granting it to the States was just passed. States have vast new flexibility to administer Medicaid as the result of the 1115 waivers. The basic data needed to address departmental policy and research issues have typically come from major, national, Federally-sponsored population-based surveys, which are designed to provide national (not State) estimates. This project focused on three major Federal surveys--the Survey of Income and Program Participation (SIPP), the Current Population Survey (CPS), and the National Health Interview Survey (NHIS)--selected for their widespread applicability, use, and potential for analyzing policy issues. The purpose of this project was to (1) understand the statistical issues involved in addressing policy and research questions at the State level with national survey data; (2) assess the current capabilities of these three major surveys to provide answers to these questions at the State level; and (3) present options for obtaining valid reliable State-level data from relatively minimal enhancements and changes to survey design.

Improving Health in the Community: A Role for Performance Monitoring (6583) draws on lessons from a number of current community health efforts to outline the elements of a community health improvement process, discusses the role that performance monitoring can play in this process, and proposes tools to help communities develop performance indicators. The report finds that a community health improvement process (CHIP) can be an important tool for developing a shared vision and supporting a planned and integrated approach to improving community health. The report suggests that a CHIP should include two principal interacting cycles based on analysis, action, and measurement. The first is a problem identification and prioritization cycle; the second is an analysis and implementation cycle.

Privacy and Health Research: A Report to the U.S. Secretary of Health and Human Services (6605) identifies privacy issues surrounding research on personally identifiable health data, paying special attention to the international aspects; reviews the ethical, legal, and general social context surrounding the privacy and confidentiality of health data; describes relevant privacy-protection practices and problems, and identifies emerging issues; analyzes the implications of the new European Union Data Privacy Directive and related policy and legal changes; and recommends policy approaches and technical processes for ensuring that the privacy of individuals is respected. The report examines four major groups of issues that are growing rapidly in scale and complexity, and that must be urgently attended to: (1) secondary uses of data and data linking, (2) research on private-sector health data, (3) cybersecurity, and (4) genetic privacy. The international flow of data, new health data privacy laws in Europe, the United States' new Health Insurance Portability and Accountability Act, and the need for dialogue between the United States and Europe are also examined in detail.

Disability, Aging and Long-Term Care Policy

State Assisted Living Policy: 1996 (4719.3) describes assisted living facilities as an expanding source of supportive housing and services that represent a new model of long-term care. Consumer choice and control are central to assisted living models, which seek to allow consumers to control key features of their living environments and to direct their own receipt of services. This study reviews policies on assisted living and board and care in each of the 50 States. One of the major difficulties associated with assisted living is the lack of a common or standard definition of this kind of care. The report provides specific information about policies in each State.

The Role of Home and Community-Based Services in Meeting the Health Care Needs of People with AIDS: Literature Review (6418.1) provides an overview of the literature (published since 1991) describing the delivery and financing of home- and community-based services for people with AIDS. The review draws inferences from literature on the provision of these services to these elderly for their potential application to the AIDS population.

Consumer-Directed Personal Assistance Services: Key Operational Issues for State CD-PAS Programs Using Intermediary Service Organizations (6728). This project examined approaches and solutions for implementing consumer-directed service models for the delivery of home and community-based personal assistance services (PAS) for persons with disabilities. It addressed issues in this area arising from regulatory compliance requirements as well as issues concerning potential tort liability faced by payers, consumers, and providers of these services. The project included case studies of up to 20 programs that use a variety of intermediaries and the services they provide; meetings with Federal officials to identify and discuss tax and labor regulations affecting PAS providers and consumers; and development of model contracts of Federal regulations and requirements in clear, simple, and accurate terms.

Human Services Policy

Evaluating Two Welfare-to-Work Program Approaches: Two-Year Findings on the Labor Force Attachment and Human Capital Development Programs in Three Sites (6576.1) examines the relative strengths and limitations of particular versions of the labor force attachment (LFA) strategy and human capital development (HCD) strategies. It includes the findings from one part of a multi-year, 7-site evaluation and draws on the advantages of a unique experimental design implemented in three sites: Atlanta, Georgia; Grand Rapids, Michigan; and Riverside, California. The evaluation had its origins in the Family Support Act of 1988, which marked a major shift in the philosophy of welfare by establishing a system of mutual obligation--between government and recipients--within the AFDC entitlement structure. The report is part of a larger study called the National Evaluation of Welfare-to-Work Strategies (formerly known as the JOBS Evaluation). It contains an analysis of the implementation, participation patterns, and costs of the two types of programs operated in each site and an assessment of the effectiveness of the LFA and HCD program approaches in promoting employment and reducing welfare.

Setting the Baseline: A Report on State Welfare Waivers (6651). The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 eliminated the entitlement to Aid to Families with Dependent Children (AFDC) and replaced it with Temporary Assistance for Needy Families (TANF), a block grant that States can use to provide cash and services to low-income families with children. This report is one in a series designed to provide baseline information on the AFDC program as it existed prior to enactment of the new law. The report focuses on the waivers of AFDC requirements that were granted to States in the years preceding enactment of PRWORA. It provides an overview of the types of waivers that States requested and received, and provides details on specific State policies.

Approaches to Evaluating Welfare Reform: Lessons from Five State Demonstrations (6050). Prior to the enactment of PRWORA, many States obtained waivers from AFDC and Food Stamp Program rules in order to implement welfare reform. Between 1993 and 1996, the Clinton administration approved waivers for 43 States. This project examined waiver demonstration projects in five States (California, Colorado, Michigan, Minnesota, and Wisconsin). Four of the five States used an experimental evaluation design, while the fifth State used a quasi-experimental evaluation design. The report addresses issues in five areas: (1) the choice between an experimental and quasi-experimental evaluation design, (2) sample design, (3) implementation of experimental evaluations, (4) data collection, and (5) analytical methods.

Implementing Welfare Reform Requirements for Teenage Parents: Lessons from Experience in Four States (6228). Federal welfare policy requires minor custodial parents receiving cash assistance to attend school and to live with their parents or in an adult-supervised setting. These requirements were established as part of the PRWORA, which created the program for Temporary Assistance for Needy Families (TANF) and abolished the Aid to Families with Dependent Children (AFDC) program. This report summarizes lessons learned from the operational experiences in four States (Arizona, California, Massachusetts, and Virginia) that implemented waivers requiring school attendance and certain living arrangements under the AFDC program.

Determinants of AFDC Caseload Growth: Final Report (5953). This project examined the dynamics of Aid to Families with Dependent Children (AFDC) caseload growth and analyzed the effects of economic, demographic, and programmatic changes at the State level on States' AFDC caseload from the early 1980's to the present. The project addressed the interaction of these factors by analyzing the economic, demographic, and programmatic factors simultaneously. Compared to earlier studies of AFDC caseload determinants, many of which are outdated, this study focused much more on State-level indicators, and included a more comprehensive set of economic, demographic, and programmatic factors.

Indicators of Welfare Dependence and Well-Being: Interim Report to Congress (6634). The Welfare Indicators Act of 1994 directed the Secretary of Health and Human Services to conduct a study to determine which statistics would be most useful in tracking and predicting dependence on three means-tested cash and nutritional assistance programs: Aid to Families with Dependent Children (AFDC), Food Stamps, and Supplemental Security Income (SSI). Enactment of the PRWORA of 1996 makes this task even more important. The report recommends two kinds of indicators: indicators of dependence, self-sufficiency, and family conditions; and indicators of child achievement, health, and well-being. In most cases, the recommended indicators should be tabulated separately for children, male non-elderly adults, female non-elderly adults, and other important population subgroups wherever possible. To measure dependence, self-sufficiency, and family conditions, the report recommends that indicators reflect points on a continuum, from total dependence to complete self-sufficiency.

Iowa's Limited Benefit Plan (6390). Iowa's Family Investment Program (FIP) replaced Aid to Families with Dependent Children (AFDC) in 1993. FIP participants who are able-bodied and not caring for young children--yet who do not develop and carry out a Family Investment Agreement (FIA)--are sanctioned with assignment to the Limited Benefit Plan (LBP). Some clients may also choose LBP over FIP. LBP originally provided 3 months of benefits at FIP levels, followed by 3 months of reduced levels and 6 months of no cash benefits; the program was later changed to eliminate the original 3-month period. At the end of the 6-month period, the client can reapply for FIP, but must meet its requirements. This report presents findings from a study of the original LBP, showing how families enter the LBP and how their well-being changes after benefits are cut. It examines records for over 4,200 cases assigned to LBP records during 6 months in 1994 and 1995, a survey of 137 cases whose cash benefits were terminated, and case studies of 12 LBP families. The authors note that there are several features of the LBP program that mitigate against extreme deprivation when cash assistance has been terminated, and that the absence of these safeguards in a national welfare reform program could result in extreme hardship for many families.

Family and Children's Social Services Policy

Informal and Formal Kinship Care (6016). A growing number of States prefer to place children who have been removed from their homes of origin in the home of a relative. This practice is known as kinship foster care and it is a growing component of family foster care. It comprises between one-third and one-half of all foster care days provided in the States with the largest foster care populations. This study uses several data sources to examine the characteristics of informal kinship care arrangements and how they compare with those initiated through or subsidized by the State child welfare system. It considers national patterns, examines living arrangement patterns by State for 1990, compares formal and informal kinship care in four States, and uses data from Illinois to provide a more focused picture of kinship care.

Trends in the Well-Being of America's Children and Youth: 1997 (6170.1). This is the second edition of an annual report on the well-being of children and youth in the United States. The report's purpose is to provide the policy community, the media, and all interested citizens with a statistical overview describing the condition of children. The report focuses on trends in the well-being of children and youth in 5 areas: (1) population, family, and neighborhood; (2) economic security; (3) health conditions and health care; (4) social development, behavioral health, and teen fertility; and (5) education and achievement.

Efforts by Child Welfare Agencies to Address Domestic Violence: The Experiences of Five Communities (6155). Historically, child protective services and domestic violence services have not been closely linked. However, child welfare agencies across the country are beginning to consider how families in their child protection caseload are affected by domestic violence and are re-examining their policies accordingly. This report documents how child welfare agencies in five communities (Massachusetts; Michigan; San Diego County, California; Hilo, Hawaii; and Oregon) are attempting to integrate domestic violence concerns into their services. The communities were chosen for study because they are extending their services well beyond educating staff in domestic violence concerns. The report includes a discussion and evaluation of approaches to addressing domestic violence within child welfare agencies; the role of the larger community in preventing domestic violence; and more complex policy questions, such as whether a child's witnessing of domestic violence is itself abusive.

Evaluability Assessment of Responsible Fatherhood Programs (6159). Responsible fatherhood programs provide fathers, particularly those who are young, unmarried, and unemployed, with the support and skills to become active participants in their children's lives. An increased interest in fatherhood programs and a lack of information on their accessibility and effectiveness led to this evaluability assessment. The study visited five fatherhood program sites to assess the readiness of the programs for outcome evaluation and to determine the evaluation process and mechanisms necessary for a full evaluation.

Chapin Hall Center for Children at the University of Chicago: Administrative Data Guide (6389). This report is a guide to administrative data resources on health, social services, and related programs available through the Chapin Hall Center for Children at the University of Chicago. Each data section in the guide provides an overview of a particular data set. Included is information to assist the researcher in interpreting the data sections. The guide was designed for use by an audience of informed policy analysts in order to consider what data are available to answer particular policy questions. ASPE will use the guide to better design short-turnaround analyses on a variety of topics of current policy interest.

Evaluations in Progress

ASPE's evaluations in progress cover a broad range of program and policy areas. In health policy, ASPE is concentrating its efforts in the four areas described below.

Studying Changes in Health and Human Services Programs. America's health care system is undergoing rapid and dramatic change. States are using a variety of laws (e.g., the Balanced Budget Act of 1997 and PRWORA of 1996), as well as Medicaid and welfare policy waivers to make substantial changes to their welfare and health financing and delivery programs. In this area, ASPE's goal is to put into place mechanisms to assess the impact of such legislative changes, the interactive effects of waivers and changes in the law, and the effects of the rapidly changing private sector environment. ASPE is supplementing ongoing private sector and foundation efforts to create a baseline of health information at the State level with projects that will help define key measurements and themes with which to monitor the effect of both program changes and changes in the environment. For example, ASPE has projects under way to examine child health insurance patterns (6721) and innovative State strategies (6729) to insure children.

Understanding Private Sector Changes. In recent years, rapid changes to health care in the private sector have transformed the landscape of health financing and service delivery systems. ASPE's goal is to understand the private sector environment in which HHS programs operate and to be able to describe and monitor ongoing changes. A better understanding of how the private sector works and the dynamics of these changes are essential to developing Federal policy. For example, ASPE is currently managing projects to evaluate the effects of "direct-to-consumer" advertising on consumer knowledge, attitudes, and behaviors concerning prescription drugs (6343) and innovative coverage of health promotion, clinical preventive services, and other coverage issues in the private sector (6347).

.Improving Data and Analytic Capability. Current projects that focus on describing, evaluating, and analyzing information to develop estimates for the decisionmaking process require resources for data collection and analytic capability. An actuarial services contract, for example, supports a wide range of analyses, including cost estimates related to legislation. In addition, the rapid evolution of the delivery system has created information gaps that need to be addressed in a comprehensive way. ASPE has several projects that are part of the HHS "Data Initiative," an effort to fill gaps in the data needed to analyze and monitor the health and well-being of the population, particularly given recent policy changes in HHS programs. This effort focuses on the need for State-level data, better linkages between health data and human service data, data on the impact of policy changes on the well-being of low-income children, and data on health care providers and the supply of employer-provided fringe benefits. For example, ASPE is exploring the linkage of data files from the National Health Interview Survey and the Survey of Income and Program Participation (6419) to be used in program evaluation. This effort emphasizes making better use of existing data.

Agency Related Priority Studies. ASPE continues to collaborate with various HHS agencies on program evaluation and technical assistance. As resources continue to shrink, the need to develop and share information on program efficiency and effectiveness assumes even greater importance. For example, ASPE is working on a number of projects with the Public Health Service (PHS) agencies regarding the food additive review process (6342), Indian health programs (6345), and the role of enabling services in the provision of health care (6750). These continue a tradition of joint projects with both the PHS agencies, as well as with HCFA on Medicare and Medicaid payment policies such as a study of managed delivery systems for Medicare beneficiaries with disabilities and chronic illnesses (6391).

In the area of disability, aging, and long-term care issues, ASPE is focusing its efforts in several areas.

Disability, Aging, and Long-Term Care Trends. ASPE has current projects to assess the profound demographic changes brought about by the aging population and the implications of these changes for active aging and health, long-term care, and retirement policies for the next century. ASPE is looking at the implications of disability for the Nation's health, long-term care and personal assistance, welfare, income security, housing, transportation, educational, civil rights, and employment policies. For example, one project is examining two large claims data sets to assess the health and long-term care expenditure patterns of children with disabilities (5758). Another project is reviewing information on how health insurance coverage and the particular provisions of health care policies are related to employment by people with disabilities. The review will consist of an examination of the available research literature on the relationship of health care coverage and employment among people with disabilities (6240).

Promoting Active Lifestyles and Maximum Independence. More seniors and individuals with disabilities can and should be able to expect to lead active and productive lifestyles of their own choosing and direction than ever before in history. There is increasing evidence that disability rates among the elderly are falling. New advances in technology, the availability of personal assistance services in the community, and the stimulus of new civil rights are empowering individuals with disabilities to live independent lives. Through policy analysis and research and demonstration functions, ASPE is identifying what is known and what remains to be learned about how to assist children and adults with the full range of disabilities to become contributing members of their families, communities, and the Nation (6719).

Managed Care and People with Disabilities. Managed care can provide unique opportunities, but it also has potential pitfalls for people with disabilities. ASPE has projects in progress to determine the impact of managed care on access, quality, and satisfaction for people of all ages who experience disabilities (6398). Of particular interest are two policy issues: (1) there is a concern about the impact of extending Medicaid managed care to the SSI-eligible disabled population, (2) the impact of managed care on elderly persons with physical and cognitive impairments needs to be examined. Evaluation of a comprehensive program for capitating acute and long-term care services for children with disabilities will be initiated.

Assisted Living. ASPE has commissioned a national study of assisted living, or the residential settings that combine adapted housing, assistive technologies, personal assistance, and other supportive services for persons with disabilities (4719.5). Assisted living is considered an important component of services to the aging American population and an effective response to the rising costs of nursing home care.

The following projects are focused on human services issues.

Moving Welfare Recipients to Work. ASPE continues to work with the Administration for Children and Families (ACF) to conduct a comprehensive, multi-year study of the different strategies designed for moving people off welfare and into employment, looking particularly at the cost-effectiveness of different approaches. The evaluation will address questions about the long-term effects of different welfare reform approaches, including whether any approach significantly improves the economic circumstances of the most disadvantaged recipients (6576.3) and the effects of welfare-to-work programs on the children of welfare recipients (6576.4). ASPE has also funded a project to look at one-stop shopping models for welfare-to-work programs (6891) and a project to examine the impact of local labor markets on welfare-to-work transitions (6892).

Measuring the Outcomes of Welfare Reform. ASPE recently initiated a project to look at the impact of employment on AFDC recipients in Wisconsin (6727), comparing the characteristics and outcomes of two groups of women who have left the AFDC program. In collaboration with ACF, HCFA, the Immigration and Naturalization Service, and the Department of Agriculture, ASPE is now studying the impact of welfare reform on the economic and health status of immigrants, their communities, and the organizations that serve them (6747). ASPE has also funded a study in New Jersey to look at changes in family well-being and family coping strategies following benefit sanctions (6893).

Welfare Reform Implementation Issues. ASPE has several projects examining human service delivery policy questions related to the implementation of welfare reform. As welfare programs require employment or participation in work-related activities, a better understanding of the low wage labor market is critical. ASPE has commissioned a series of papers to summarize and interpret the results of previous research on the low-wage labor market (6717). ASPE will examine the relationship between domestic violence and welfare reform (6724) by looking at implementation of the TANF Family Violence Option, changes in child support enforcement programs, and the use of good cause waivers for battered women. Evidence suggests that some battered women seek employment and child support while others need specialized assistance in addressing the abuse of partners. A third example is ASPE's study of child health and development programs in the context of welfare reform (6754). This project will identify and present profiles of promising Federal, State and/or community-based health and human services programs believed to be enhancing the health and development of children in the context of welfare reform.

Child Support. ASPE will examine the impact of a change in child support review and modification policy under PRWORA (6749). The law prior to the enactment of PRWORA required that all AFDC child support cases be reviewed every 3 years and adjusted if the child support award was inadequate. PRWORA made review and modification in TANF cases optional. A number of States may discontinue review and modification in TANF cases. This project will provide estimates of the financial impacts to the Federal and State governments, or how such a discontinuance would impact on child support offsets to cash assistance payments. In addition, the financial impacts on families are to be estimated, paying particular attention to those who have left the welfare rolls.

Family Preservation Services. ASPE and ACF are now examining the following types of family preservation programs: placement prevention services aimed at preventing children from entering substitute care; broader family preservation services that may be less intensive and of longer duration than placement prevention services; and reunification services to speed the return of children to their homes after entering substitute care (5337.2). Measures of program success will include prevention of placement of children into substitute care (for pre-placement services), successful reunification (for reunification services), improved child behavior, improved family functioning, and reduction of the recurrence of child abuse and neglect.

Teen Pregnancy. ASPE is coordinating several efforts with HHS agencies to develop and evaluate strategies to reduce teen pregnancy. The first project is part of the National Strategy to Prevent Teen Pregnancy, aimed at furthering our knowledge about teen pregnancy prevention programs and the process of building and strengthening partnerships to reduce teen pregnancy and provide a positive future for youth (6725). ASPE will provide information and tools to help communities develop teen pregnancy prevention programs and partnerships. Next, ASPE will conduct a project on understanding and preventing abusive intimate relationships among adolescents (6751). It will examine the issue through a literature review; analysis of newly available data from the National Longitudinal Study of Adolescent Health, the National Survey of Family Growth, and other surveys; identification of data needs; focused discussion groups; a summary of promising approaches to prevention and intervention; and recommendations for further research, policy, and discussion. Finally, ASPE has two teen pregnancy prevention efforts that target young men. First is a project to develop a research and policy information strategy to inform regional, State, and local policy officials and community-based organizations serving children and youth of the program models--primarily directed at boys and young men-- that can be implemented to help teenagers avoid premature sexual activity and unintended pregnancies (6766). Second, there is a project is to identify abstinence-based pregnancy prevention programs that target boys or both boys and girls (6726). It will use a framework to assess and summarize the state of the field and provide the information in a format useful to State, local, and community policymakers. States and communities have shown interest in providing services and programs for boys and young men, but have also expressed frustration that they do not have access to information about what strategies have been tried, if they have been successful, and how they can access funding for the development and operation of these programs.