Health Policy Commons^™

Aids: An Overview, Loretta Mclaughlin

New England Journal of Public Policy

"We stand nakedly in front of a very serious pandemic, as mortal as any pandemic there ever has been," said Halfdan Mahler, director-general of the World Health Organization (WHO). "I don't know of any greater killer than AIDS, not to speak of its psychological, social and economic maiming. Everything is getting worse and worse with AIDS and all of us have been underestimating it, and I in particular. We're running scared. I cannot imagine a worse health problem in this century." When asked to compare AIDS to other epidemics, such as smallpox, that have infected and killed over the course …

The Citizens Health Prescription: Coping With Rising Drug Costs, Shannon Cadres

New England Journal of Public Policy

Prescription drug prices have climbed to unaffordable levels in recent years, creating a serious public policy problem for lawmakers at both the state and federal levels. The U.S. Medicare program only covers the costs of inpatient prescription drugs, and only seventy-five percent of beneficiaries are receiving coverage through some other means. But because of the tremendous power of the pharmaceutical industry on Capitol Hill, lawmakers in Washington have been unable to agree upon a workable solution. As a result, many states are experimenting with different strategies to provide some relief. Massachusetts has attempted to solve the problem through the Prescription …

Environmental Public Health Awaits Rediscovery, Anthony Robbins, Phyllis Freeman

New England Journal of Public Policy

Preventing environmental exposures that threaten human health remains among the best but least attended to opportunities to improve everyone’s health. For more than a decade, medical care concerns, exacerbated by voracious competition among medical empires and the implacably growing number of uninsured, have often been misconstrued as constituting a complete agenda for health system reform. The authors explain the predicament from an historical perspective — how defining events moved U.S. health policy away from protecting the public against dangerous exposures toward unrealistic expectations that doctors will fix whatever goes wrong, at least for individuals with ample medical insurance. They explain …

Nursing Homes To Medicare Waiver Programs In Vermont, Joseph Murray

New England Journal of Public Policy

This research examines the differences between nursing home residents and those who were able to leave nursing homes with the help of the Medicaid Waiver Program in Vermont. Ninety individuals who reentered the community with the aid of such waivers were compared with a random sample of nursing home residents through the use of the Nursing Home Minimum Data Set. The researchers found divergence in four key areas: cognition, continence, treatment categories, and desire to return to the community. Typically, those who left nursing homes for the community were cognitively intact, had moderate continence, received rehabilitative or clinically complex treatments, …

Institutional Design And Regulatory Performance: Rethinking State Certificate Of Need Programs, Robert Hackey, Peter Fuller

New England Journal of Public Policy

The success of state efforts to control rising health care costs depends on the incentives contained in the legislative design of regulatory policies and in the administrative capacity and autonomy of state agencies. States have regulated the construction and expansion of health care facilities and services for more than two decades through "certificate of need" (CON) programs designed to limit the diffusion of expensive new medical technologies and to avoid the duplication of health care facilities. Although the cost-control record of state certificate of need programs has been widely criticized, Rhode Island's experience with a reformed CON process from 1985 …

The Professional Decline Of Physicians In The Era Of Managed Care, Aimee E. Marlow

New England Journal of Public Policy

Physicians have long enjoyed prestige, power, and autonomy, but the rise of managed care organizations has drastically changed their status. Many doctors are in thrall to the financial well-being of the corporations that employ them, their knowledge and expertise controlled and manipulated in the interest of profit maximization. This article investigates the professional decline of physicians, citing the use of gag clauses, incentives to withhold care, and the breakdown of their authority. In an effort to regain some measure of control, physicians have taken their concerns to the public, supporting state and federal legislation that attempts to curb questionable managed …

Labor's Response To Hospital And Workplace Transformation, Enid Eckstein

New England Journal of Public Policy

The health care industry and the nation's hospitals are in the throes of revolutionary change. The shift to managed care resulted in fundamental changes in the delivery of care and the structure of health care, For the past ten years, hospitals have actively been merging and creating large-scale integrated delivery systems. Employers, eager to expand market share and reduce costs, are engaged in radical reorganization of the hospital and the structure of work from which no group is immune. Physicians, nurses, technicians, and housekeepers are all affected by these changes. Hospitals are reducing their personnel, shifting work outside the hospital, …

Nursing: A New Day, A New Way, Lin Zhan, Jane Cloutterback

New England Journal of Public Policy

The U.S. health care environment is changing rapidly. Its structure, financing, and delivery are being reconfigured toward an integrated system based on managed care. Increasingly, national interest in health promotion and disease prevention is moving care away from a disease-oriented, institutionally based model to a population-focused, wellness-oriented, and community-based system. Health care consumers are diversifying in age, ethnicity, and socioeconomic status. The approach emerging from these changes and others requires nursing to rethink, redesign, and retool its workforce to meet new challenges. This article analyzes nursing education, practice, and operations. The authors discuss the dilemmas and complexity of developing an …

We Are The Roots: The Culture Of Home Health Aides, Ruth Glasser, Jeremy Brecher

New England Journal of Public Policy

This article focuses on the contributions of its workers' culture to the success of Cooperative Home Care Associates (CHCA). It examines what the home healthaides bring to the culture of the company, how their contribution develops through their experience with the company, and how their heritage contributes to their CHCA work and to the company as an organization. This is one segment of a larger study that will deal with the background and history of CHCA, the vision of the founders and its implementation, the role of organizational policy, and the contribution of management philosophy to its accomplishment.

Performance And Accountability In Human Services: Ownership And Responsibility Of Professionals, Anna-Marie Madison

New England Journal of Public Policy

The recent frenzy of grant makers and government agencies in requiring impact evaluations of all grant recipients has created consternation among human service providers. To ensure their agencies' survival and worker job security, the leaders are faced with meeting the demands offunder-driven programming. Agencies seeking funding must comply with funder-defined needs and accountability criteria rather than their public missions. This article describes the use of mission-based performance evaluation rather than funder compliance to demonstrate accountability for mission accomplishment.

Improving Workforce Conditions In Private Human Service Agencies: A Partnership Between A Union And Human Service Providers, James Green

New England Journal of Public Policy

In 1995 the Service Employees International Union Local 509 and four Massachusetts human service providers signed an unusual agreement to forge a partnership in which employers would remain neutral while the union approached its workers with an offer to advocate in the state legislature for greater funding for private human service employees and to promote cooperative relations with their employers. This study examines the context of the agreement and the pressures on public employee unions and small human service providers whose workforce copes with low wages, high turnover, meager benefits, and poor public image as well as the give-and-take between …

Foreword, Andrés Torres, James Green

New England Journal of Public Policy

Many important debates about public policy at the national level and in states like Massachusetts have centered on health care and human services, including welfare and the care of children, the abused, the disabled, the elderly, and those suffering from mental and physical illness. In this issue scholars and advocates examine a range of problems in the health care and human service fields from a perspective often lacking in the public policy discussion — that of the workforce and of the labor organizations that represent the workforce.

The Potential Impact Of Workforce Development Legislation On Cbos, Edwin Meléndez

New England Journal of Public Policy

The proposed congressional legislation revamping the employment and training system will result in budget cuts, program consolidation, and block grants for the states. These changes are potentially harmful to community-based organizations (CBOs) because (J ) they eliminate categorical funding that traditionally has required contracting with organizations which specialize in servicing the disadvantaged, and (2) they introduce stricter performance standards that may be unattainable for many small-scale operations. However, the adoption of best practices in serving non-English-speaking and poor populations, increasing connections to emerging government intermediaries in labor markets, and establishing greater linkages to postsecondary educational institutions may offer CBOs the …

Downsizing The Massachusetts Mental Health System: The Politics Of Evasion, Richard A. Hogarty

New England Journal of Public Policy

For the past three decades the topic of the proper role of state mental hospitals has been vigorously debated as a major public policy issue in Massachusetts. The state has had two runs at hospital closings: the first between 1973 and 1981, when the deinstitutionalization policy flourished, the second between 1991 and 1993, when the privatization policy was developed. In making the case for this seismic shift, a governor's special commission concluded that the state had too many hospitals for too few patients at too high a cost. This study provides a detailed analysis of the problems that beset the …

Understanding Latino Ethnic Identity Development: A Review Of Relevant Issues, Azara Rivera-Santiago

New England Journal of Public Policy

One of the most promising areas in cross-cultural psychology is the development of identity among various ethnic groups in the United States. This article has a twofold purpose. First, it offers the concept of ethnic identity as defined and studied within the social sciences — sociology, anthropology, and psychology — including a review of some of the recent work on ethnic identity development proposed by leading investigators in the field of psychology. The author discusses their generalizability across ethnic groups. Second, it presents a number of dimensions considered important in conceptualizing and studying Hispanic ethnic identity development. These include acculturation, …

The Health Status And Lost Earnings Of Hispanic And Non-Hispanic Women, Janis Barry Figueroa

New England Journal of Public Policy

Based on data from the 1990 early release file of the Latino sample of the Panel Study of Income Dynamics (PSID), this article examines the loss of earnings suffered by disabled or health-limited Hispanic women workers. For comparative purposes, the author created an identical analysis based on a sample of black and white non-Hispanic women from the 1989 original-sample PSID. The research also considers the prevalence of poor health among Latinas to ascertain whether their lower labor-force participation, earnings, and number of hours worked can be associated with episodes of poor health. The empirical results show that Hispanic women are …

Foreword, Martha Montero-Sieburth, Ralph Rivera

New England Journal of Public Policy

These articles echo the issues of today that will have an impact on the future and help us understand how current thinking about ethnicity, education, and health within Latino populations presents opportunities for the coming century. The Latino presence in the United States will certainly make itself known. As Richard Rodriguez poignantly reminds us, "We will change America, even as we will be changed."

Puerto Ricans' Access To Health Care, Ralph Rivera

New England Journal of Public Policy

The shift toward cost containment in health policy over the past decade has had negative consequences for the most vulnerable populations in the country, namely, ethnic minorities, the poor, and the uninsured. The Puerto Rican population is significantly affected by this shift, yet little is known of their health care usage. This study investigates the extent to which Puerto Ricans' health care use is determined by the relationship between predisposing variables, enabling variables, need, and other contextual variables and probes the implications of the findings for health policy. The adult Puerto Rican subsample (n = 1598) of the Hispanic Health …

Health Care: An Economic Priority, Dolores L. Mitchell

New England Journal of Public Policy

Economic advancement for women may be inextricably linked to the state of their health and access to health care. This article warns that the debates and public policy dilemmas over health care delivery systems, their costs, who pays, and issues of coverage and utilization demands weigh greatly on women and their families. The author suggests that women especially must be careful consumers of health care plans and outlines some qualities they should seek in choosing such plans.

Alcoholism: A Barrier To Empowerment For Women, Marion Brink

New England Journal of Public Policy

Women's increasing economic power has encouraged the promotion of their drinking as fashionable. However, women are more vulnerable to the impact of alcohol, and the stigma attached to alcoholism is greater for them than it is for men. As a consequence, a woman — and those around her — will deny her alcoholism until she has lost much more than her male counterparts. When, or if, she seeks help for this devastating disease, she finds a lack of woman-specific programs and facilities. This article notes the barriers to recovery for women and offers some suggestions for breaking them down. Two …

Medicaid And Medicaid Cost Containment In Massachusetts, Fredric A. Waldstein

New England Journal of Public Policy

The purpose of this article is to describe Medicaid's financial structure and examine cost containment efforts to limit future growth of the program, particularly pertaining to Massachusetts. The principal focus is the Massachusetts Department of Public Welfare and the Massachusetts Medicaid Fraud Control Unit, the two agencies most responsible for Medicaid cost containment in the commonwealth. Because elected officials are unwilling to face directly the troublesome issues surrounding Medicaid and its growth, the government agencies responsible for cost containment have been left to define the scope of the problem, design remedial strategies, and evaluate their success. This process is found …

Editor's Note, Padraig O'Malley

New England Journal of Public Policy

On occasion, the New England Journal of Public Policy will devote an entire issue to consideration of a public policy matter of major importance. The AIDS epidemic is such a matter, with a likely impact of overwhelming consequence well into the twenty-first century. The epidemic raises fundamental questions regarding the nature of individual freedom, our responsibilities to others, the always delicate balance between private rights and the public interest, and society's obligation to its "out" groups — whose members it has stigmatized, discriminated against, ridiculed, and treated as less than full and equal citizens. Indeed, it requires us to ask …

The Acquired Immunodeficiency Syndrome In New England: An Epidemiological Review Of The First Six Years, Laureen M. Kunches, Jeanne M. Day

New England Journal of Public Policy

Between 1981 and 1987 — the six-year period following initial recognition of the acquired immunodeficiency syndrome (AIDS) — 1,475 cases were reported among residents of the six New England states. Of nearly 40,000 cases nationwide, 3.8 percent occurred among New England residents, though the region 's population represents 5.5 percent ofthe total United States population. The groups most affected include homosexual or bisexual men (65 percent) and intravenous drug users (20 percent). However, in the two southernmost states — Rhode Island and Connecticut — 32 to 40 percent of all cases have used intravenous drugs. In these states, the male:female …

The Quest For An Aids Vaccine, Robert T. Schooley

New England Journal of Public Policy

More than fifty thousand cases of AIDS have been reported in the United States since the disease wasfirst described in 1981. Many times this number of people are infected with human immunodeficiency virus (HIV), which has been identified as the agent responsible for the illness. The seriousness of the disease, coupled with the relatively rapid spread of HIV, has fueled the effort for development of an effective vaccine.

Much is now known about the life cycle of the virus, and about its structural components. This information, and information about methods of transmission of the virus, form the basis for a …

Aids: Prophecy And Present Reality, Victor De Gruttola, William Ira Bennett

New England Journal of Public Policy

Mathematical modeling of the AIDS epidemic can be useful for policymakers even though precise projections are not possible at this time. Models are useful in establishing ranges for current and future prevalence of HIV infection and incidence of AIDS, as well as in predicting the effect of a given intervention strategy. Most decision makers are using models implicitly when they use epidemiological information as a basis for policy; formulating a model explicitly permits examination of the underlying assumptions. By creating and testing a variety of models, an investigator can determine whether the models reflect more the underlying assumptions or the …

Understanding The Psychological Impact Of Aids: The Other Epidemic, Marshall Forstein

New England Journal of Public Policy

HIV has created two epidemics, one of disease, the other the consequence of the psychological response to that disease. Thus far, behavioral change is the only effective means of interrupting the transmission of HIV. The underlying psychological dimensions of the societal and individual responses to AIDS are discussed, with suggestions for how both rational thinking and irrational fears and anxiety contribute to the development of public policy. Examples are given of how short-term solutions to reduce anxiety may actually create long-term problems, potentially increasing the risk of transmission of HIV. Specific psychological mechanisms that contribute to the epidemic of fear …

U.S. Women And Hiv Infection, P. Clay Stephens

New England Journal of Public Policy

Women are inadequately provided with HIV services and education and are differentially denied access to these. Divisions of race, ethnicity, economic class, and religion, among others, are compounded by sexual discrimination within each of these categories.

Review of current data on women with AIDS reveals that the reporting methods used convey a false impression that women are not at significant risk. Moreover, the persons indirectly affected by AIDS are predominantly women — mothers, sisters, partners, family members, teachers, and human service workers. Thus, AIDS is more of a women's issue than the statistics imply.

Women, as a gender-defined class, face …

List Of Terms

New England Journal of Public Policy

Lists and defines terms relevant to the study of HIV/AIDS that are used throughout this issue of the New England Journal of Public Policy.

Aids: An Overview, Loretta Mclaughlin

New England Journal of Public Policy

"We stand nakedly in front of a very serious pandemic, as mortal as any pandemic there ever has been," said Halfdan Mahler, director-general of the World Health Organization (WHO). "I don't know of any greater killer than AIDS, not to speak of its psychological, social and economic maiming. Everything is getting worse and worse with AIDS and all of us have been underestimating it, and I in particular. We're running scared. I cannot imagine a worse health problem in this century." When asked to compare AIDS to other epidemics, such as smallpox, that have infected and killed over the course …

Neuropsychiatric Complications Of Hiv Infection: Public Policy Implications, Alexandra Beckett, Theo Manschreck

New England Journal of Public Policy

The human immunodeficiency virus (HIV) infects the central nervous system (CNS), causing symptoms in most persons with AIDS-related complex (ARC) and AIDS, and in a significant proportion of those classified as asymptomatic seropositive. The most common clinical syndrome secondary to CNS infection is known as HIV encephalopathy. When sufficiently disabling, HIV encephalopathy is known as AIDS dementia, and must be reported to the Centers for Disease Control as a case of AIDS.

AIDS dementia is a complex of cognitive, affective, behavioral, and motor symptoms which varies widely in its presentation. In some persons, cognitive impairment predominates, manifesting in a loss …