From rejection to resignation: beneficiaries' views on the South African government's new housing subsidy system

South Africa's housing policy arose from a multi-party negotiating body, the National Housing Forum, made up of representatives of the housing sector and key political constituencies. Negotiations carried out over a two-year period (1992-94) resulted in a housing delivery approach whereby government facilitates a framework in which the private sector carries out the delivery of 'incremental housing'. This paper briefly describes the process through which the policy was formulated and presents the policy framework and the key programme through which the housing options are to be delivered. It offers the first attempt to gauge beneficiaries' feelings about their experience in accessing a subsidy; their views about their levels of satisfaction with their new housing option; and tests whether policy options negotiated by the stakeholders at the NHF matched the preferences of beneficiaries.

The status of local health care safety nets

This paper examines variations in the composition, concentration, financing, and community context of local health care "safety nets" and the market pressures that they face. It also reviews financing mechanisms that support these systems and strategies being undertaken to retain publicly insured patients. As safety-net providers compete more aggressively, the availability of the public health, behavioral health, and social services they provide may be affected. Communities may have to consider more explicit investments in these "public goods" if competitive markets remove existing cross-subsidies.

Annual update of the HHS poverty guidelines--HHS. Notice

This notice provides an update of the HHS poverty guidelines to account for last (calendar) year's increase in prices as measured by the Consumer Price Index.

Variations in take-up of the Family Fund

This paper investigates geographical variations in successful and unsuccessful applications to the Family Fund Trust which provides grants to families with severely disabled children. A new measure of take-up is developed which takes account of demographic differences between local social services authorities and relates local take-up levels to national rates. The take-up of grants varies more than twofold across local authorities but is generally higher in deprived areas, suggesting that the help available from the fund is targeting those most in need. Nonetheless use of the fund is less than expected in metropolitan areas characterized by rented accommodation, high rise dwellings and minority ethnic groups. Ethnic monitoring and other measures to promote equal opportunities have recently been introduced. If take-up were uniformly high across England and Wales the current caseload and budget would increase by more than half. Local authorities where renewed efforts might be most effectively targeted to encourage families to apply for a grant can be identified but any publicity would need to ensure that inappropriate applications are kept to a minimum.

Purchasing of services contracting: a symbiosis of voluntary organizations, government, and clients

In the last twenty years, the phenomenon of government contracting with nonprofit human service organizations to deliver welfare services has intensified. This phenomenon, also known as privatization or purchase of services, is intriguing for welfare as well as nonprofit scholars. Using the functional-structuralist approach, the author explores analytically the mutual benefits as well as risks involved in contracting. He reviews four theoretical approaches regarding the evolution and function of voluntary organizations and how they and the public authorities divide the provision of welfare services. He discusses what each party gains, how each party takes advantage of this arrangement, and how these relationships affect services and clients. This article is based on personal experience in the U.S.A. and Israel as well as the literature from other countries including many European countries. Finally, he proposes that the framework presented in this article guide a cross-national, empirical analysis of the relationships between nonprofits and governments in welfare provision and its consequences.

Re-engineering the public hospital system: saving the safety net

Cities across America are grappling with the problem of how to provide care for the indigent and those on Medicaid. All levels of government are reducing their public funding for health care of indigent persons, and the rapid growth of managed care is making traditional cost-shifting more difficult as it transforms the practice of medicine itself. These issues are most acute in cities like Los Angeles and New York, which traditionally have relied on public hospital systems to serve as a safety net. This article focuses on the changes being wrought at the largest health-care system in the country for indigents, the New York City Health and Hospitals Corporation (HHC), on the progress it made during the first 18 months of a major re-engineering process, and on potential options for its future reform.

Showdown time

There may not be a train wreck this fall, but that doesn't mean that there won't be some close calls as the White House and Congress come to grips on such issues as spending and taxes, health care, welfare and the environment.

Psychache in context:states'spending for public welfare and their suicide rates

This analysis draws together the concept of psychache that describes the psychological pain associated with suicide and Durkheim's social integration theory in analyzing the relationship between states' spending for public welfare and their suicide rates over a 30-year period, from 1960, 1970, 1980, 1985, and 1990. Given that the threshold for enduring psychological pain varies from person to person, the questions were: Does suicide also vary with social context and has this changed over time? The answer to both questions was yes. Whereas the prevalence of divorce in combination with low population density and high rates of population change provided the context for interstate differences in suicide rates over the entire observational period and accounted for their increased variability in 1970 and 1980, this was not the case in 1985 or 1990. In both 1985 and 1990, the two variables that were important in this regard were states' spending for public welfare and race. In 1990, not only were suicide rates higher in states that spent less for public welfare than in states that spent more, but states' spending for public welfare was the only variable that accounted for the widening of differences in states' suicide rates. Given the strong prevailing skepticism that government can help solve people's problems and widespread antagonism toward government social spending, these findings carry an important message.

Families' perceptions of their resources for caring for children with developmental disabilities

Factors related to families' perceptions of internal resources when raising children with developmental disabilities were examined. Families enrolled in a Cash Subsidy Program were surveyed about their resources, use of services, and helpfulness of social supports. Parents saw their basic resources for daily life as adequate. However, they reported that their time, discretionary money, and child-care resources were not adequate for caring for their children. Helpfulness of social supports, the children's characteristics, and income were related to perception of resource adequacy. Findings suggest that support services must be flexible in the types and amounts of services provided.

Damage to urban infrastructure and other public property from the 1989 Loma Prieta (California) earthquake

This research project investigated the damage to public property caused by the 1989 Loma Prieta earthquake. The claims filed by state and local governments, special districts and non-profit organizations under the Federal Emergency Management Agency's (FEMA) disaster assistance program were analyzed to understand better the pattern of damage caused by the earthquake. These claims accounted for nearly $600 million. The damage distribution was very skewed with eleven agencies claiming more than 70 per cent of this total. Non-profit agencies accounted for a surprisingly large portion of overall damage. Heavy damage was concentrated in relatively few areas. The extent of damage in an area was a function of concentration of property, site conditions, characteristics of building stock, and distance from the epicenter.

Medical negligence in a developing country

This article reviews medical malpractice in developing black African countries in the context of the limitations and constraints placed on professional practice in these countries. Financial, infrastructural, educational, cultural, religious, political and historical factors all play a crucial role in the provision of health care, and societal values are reflected in patients' expectations regarding acceptable professional performance and the liability of doctors for medical negligence.

Savings achieved by giving WIC benefits to women prenatally

The Special Supplemental Food Program for Women, Infants, and Children (WIC) provides supplemental food, nutrition and health education, and social services referral to pregnant, breastfeeding, and post-partum women, and their infants and young children who are both low-income and at nutritional risk. A number of statistically controlled evaluations that compared prenatal women who received WIC services with demographically similar women who did not receive WIC services have found WIC enrollment associated with decreased levels of low birth weight among enrolled women's infants. Several also have found lower overall maternal and infant hospital costs among women who had received prenatal WIC services compared with similar women who did not receive prenatal WIC services. A meta-analysis of the studies shows that providing WIC benefits to pregnant women is estimated to reduce low birth weight rates 25 percent and reduce very low birth weight births by 44 percent. Using these data to estimate costs, prenatal WIC enrollment is estimated to have reduced first year medical costs for U.S. infants by $1.19 billion in 1992. Savings from a reduction in estimated Medicaid expenditures in the first year post-partum more than offset the cost of the Federal prenatal WIC Program. Even using more conservative assumptions, providing prenatal WIC benefits was cost-beneficial. Because of the estimated program cost-savings, the U.S. General Accounting Office has recommended that all pregnant women at or below 185 percent of Federal poverty level be eligible for the program.

Annual update of the HHS poverty guidelines--HHS. Notice

This notice provides an update of the HHS poverty guidelines to account for last (calendar) year's increase in prices as measured by the Consumer Price Index.

Unifying the poverty line: a critique of maintaining lower poverty standards for the elderly

Since 1982, the elderly poverty rate reported by the U.S. Census Bureau has fallen below the rate for the nonelderly population. This is cited as evidence of the success of U.S. social policies to benefit the elderly. But lower elderly poverty rates are an artifact of the fact that a lower, more stringent poverty line is applied to the elderly living in one- and two-person households, who constitute 85% of elderly persons. If the same poverty standard is applied to the elderly as to the nonelderly, the poverty rates are the same or slightly higher. The poverty line was originally based on the cost of an adequate diet. The lower standard for the elderly was based on the fact that the elderly consume fewer calories than nonelderly adults. This article shows there is no justification for this lower standard, and recommends its elimination. The overall nutrient requirements of the elderly are not lower, and the elderly spend a higher proportion of their budgets on food and on other necessities (shelter, health care) than the nonelderly. Alternative units of analysis examined under different income-pooling assumptions also show that poverty rates are not lower among the elderly than the nonelderly.

Aging policies, entitlements, and the deficit

Regardless of the good intentions of the Clinton Administration, there will not be enough money now, or in the foreseeable future, to expand entitlements adequately and fund domestic programs on the scale desired to meet all, or even most, needs in health, in housing, in crime control, in welfare, in employment, and in community-based care. This article examines the source of the problem--the nonmarket economy. There are three strategies on which societies have historically relied to fill unmet needs: market incentives, psychological incentives, and coercion. A fourth strategy, local, tax-exempt currency--called service credits, or Time Dollars--which combines market incentives and psychological rewards is described. The article summarizes what we know about why Time Dollars work. The article recommends that the Clinton Administration use already mandated and earmarked funds to undertake systematic experimentation with this currency, using elders to help with the problems of long-term care and neglected, abandoned, and abused children.

The invisible women: caregiving and the construction of AIDS health services

In health services research about the utilization by and financing of health services for people with AIDS, women kin as caregivers virtually disappear and the sacrifices made by women kin become socially invisible. Any role that women play is subsumed under the rubric "community care." The health services perspective is contrasted with the lived realities of caregiving by women kin as documented in data from a "needs assessment" of people with AIDS which the New Jersey Department of Health commissioned and then disregarded. The disregarding of women's caregiving is part of larger hegemonic processes that maintain concealed structures of domination.

Predicting hospital charge and length of stay for congenital heart disease surgery

Three hundred twenty-two consecutive operations between December 1985 and December 1989 for 10 types of low-risk congenital cardiac malformations were reviewed to determine the hospital charge and postoperative length of stay. Multiple regression analysis of variance was used to predict the influence of the primary diagnosis and various preoperative parameters. The average hospital charge was $27,262 +/- $20,644 and the postoperative length of stay was 9.3 +/- 8.3 days. Age at operation alone did not influence the dependent variables. The diagnosis of atrial septal defect (p = 0.002) or coarctation of the aorta (p = 0.002) decreased the mean charge, whereas the 8 other primary diagnoses did not significantly influence the mean charge. Other preoperative factors found to be predictive of increased hospital charge were: the date of operation (p < 0.001), cyanosis (p = 0.008), previous thoracic surgery (p = 0.02), failure to thrive (p < 0.001), associated major extra cardiac anomalies (p < 0.001), oxygen requirement (p = 0.02), and distance > 100 miles from home to hospital (p = 0.05). A primary diagnosis of atrial septal defect decreased the mean postoperative length of stay by 3.1 days (p < 0.001). Other preoperative conditions increased the mean postoperative length of stay: major extracardiac malformation (p < 0.001), failure to thrive (p < 0.001), and oxygen requirement (p = 0.003). Charge and length of stay equations were generated which may assist in the prediction of resource utilization in this patient population.(ABSTRACT TRUNCATED AT 250 WORDS)

The fiscal impact of the Medicaid abortion funding ban in Michigan

OBJECTIVE

To assess the increased public assistance costs resulting from Michigan's 1988 ban on Medicaid funding of abortions.

METHODS

The increased number of births resulting from the Medicaid abortion funding ban was estimated. The costs of this increase in births to the state and federal governments were then calculated.

RESULTS

Using low and high estimates for the numbers of additional children born as a result of Michigan's prohibition of Medicaid abortion funding (2120 and 5800), and the likelihood of these children's remaining on welfare, the 1991 cohort of infants will cost the state's taxpayers $23.1-63.2 million--several times the $6-7 million cost of the abortions, had they taken place. Including the federally paid share, total incremental costs are $50.2-137.4 million.

CONCLUSION

Those who have advocated banning Medicaid funding of abortions to reduce government spending, as in Michigan in 1988, have ignored the much greater cost of requiring that those pregnancies be carried to term.

Home improvement and structural alterations (HISA); increase in the limit for home improvement and structural alterations (HISA)--VA. Final regulations

The Department of Veterans Affairs (VA) is amending its regulations that govern expenditures for home improvements or structural alterations for veterans. The Veterans' Medical Programs Amendments Act of 1992 authorized increases for home improvements or structural alterations from $2,500 to $4,100 for service-connected veterans and from $600 to $1,200 for nonservice-connected veterans. This amendment will make the regulation consistent with the law.

Training and employment programs in methadone treatment: client needs and desires

Training and employment programs (TEP) in methadone treatment have declined in recent years. Yet heroin abusers who enter methadone treatment have historically high unemployment and low earnings compared to the general population and other treatment modalities. This paper reports on the first phase of a multiyear project to develop and evaluate TEPs for methadone treatment clients. Preliminary findings from the treatment intake survey of the pilot study are used to identify client needs and desires. Specifically, we report descriptive statistics for clients' (a) demographics, (b) education and training, (c) employment status, (d) income and expenditures, (e) interest in a TEP, and (f) labor market expectations thereafter. We conclude with a presentation of our proposed future analyses and a discussion of the policy implications of the project. Our main finding is that most addicts have a strong interest in training and employment services, but their expectations about the impact of such services is often unrealistic.

The challenge ahead: the state agenda for the coming years

The mid-1990s promise to be extremely challenging years as state leaders and institutions struggle to bring accountability and predictability back into their political systems. Faced with continuing budgets troubles, increasing demands for services and a shift of responsibility from the federal to the state level, the American states will be hard pressed to satisfy constituent needs or improve state services. However, the tough times may result in long-term improvement in state government, as administrators streamline agencies, legislators trim inefficient or redundant programs and state leaders generally seek new and cost effective solutions to social and economic problems.

The welfare state, class, and gender

If we compare the welfare state countries with others, from the point of view of both health and health services, the crisis concerns primarily the second group of countries. Nevertheless, difficulties arise also for welfare state policies. The problem is how to respond to neoconservative attacks on social and health rights, and how to change the bureaucratic and medicalized bias of the welfare state. The "golden era" of social insurance and health services, conceived as free access to funds to cope with all the growing needs of the population, is over. Limitations, controls, and priorities have to be established. In Italy and similar countries, the tendency is toward restricting health care for those who have greater needs, cutting funds for prevention, and creating greater inequalities. It is clear that the state must intervene to reduce social inequalities, but at the same time some existing differences (sexual, cultural, ethnic) have an intrinsic value that must be recognized. A policy of free-choice welfare is useful, and has nothing to do with the selective measures that are being introduced. Moreover, a key point has become the relationship between class and gender. The working class continues to be exploited, but new phenomena arise, connected with production and social reproduction and not limited to this sphere. It is true that gender includes social classes, but no social class may represent both sexes, or different ethnic groups, or gender itself.

Use and impact of a cash subsidy program

The use and impact of a $256.74 monthly cash subsidy by 1,283 families with children who have severe disabilities were examined. Families reported a variety of uses, including the purchase of clothing, toys, sitters, diapers, special foods, adaptive equipment, and professional services. Families at lower income levels used the subsidy to meet basic needs more often than did families at higher income levels. Families indicated that the subsidy was very helpful in meeting special needs and had improved family life, eased financial worries, and reduced stress. The influence of the availability of the subsidy on continuing family-based care was examined.

[High and low use of insurance benefits. A comparison of 2 Norwegian municipalities--Båtsfjord in Finnmark and Vik in Sogn and Fjordane]

Health insurance benefits and social welfare support has been investigated in two municipalities in Norway, Båtsfjord in the northernmost part of the country and Vik, in the county of Sogn and Fjordane in the western region. Båtsfjord is mainly a fishing community and 30% of the inhabitants aged 16-66 were receiving health insurance benefits, as compared to 8% in Vik, where the main sources of income are agriculture, industry and tourism. More than half of the insurance benefits contributions were permanent pensions. In addition 12% of the population in Båtsfjord and 1% in Vik received social welfare benefits. Most of the recipients of these benefits were younger than 35 years. The authors discuss the main reasons for these differences in public economic support among residents of the two municipalities. Factors such as level of education, conditions on the labour market and attitudes among the population and health personnel concerning public economic assistance through the health insurance system seem to be conducive to the steadily higher consumption of public welfare benefits.

Cognitive impairment and disruptive behaviors among community-based elderly persons: implications for targeting long-term care

This study estimates the prevalence of cognitive impairment and disruptive behaviors among functionally disabled elderly persons living in the community. The relationship between cognitive impairment, disruptive behaviors, and functional limitations is assessed. The impacts of adding cognitive and disruptive behavior eligibility requirements to commonly used functional disability criteria for long-term care benefits on the number of eligible persons are estimated. The number of eligible persons varies greatly under different criteria, depending on how cognitive and disruptive criteria are combined.

[Severely handicapped persons living at home]

The records of 34 economically demanding cases according to the Danish legislation on public assistance section 48, part 3 or the legislation on pensions section 17 were reviewed. The persons concerned were mainly young people who remained in their own homes despite severe handicap. Where 2/3 were concerned, progressive disease appeared to be involved. In addition, economical deliberations and assessment of the quality of life were considered.

Underinsurance for severe mental illness

Mental health care for the severely mentally ill in the United States is financed by a combination of public and private funds. Both public and private health insurance programs handle mental illness differently than they do other illnesses. This article documents uninsurance and underinsurance for severe mental illness in the United States based on studies conducted during the last decade. The relationship between private insurance and public assistance is analyzed, and major arguments around equality in insurance coverage for severe mental illness are examined. Alternatives for reducing uninsurance and underinsurance for severe mental illness in order to avoid undertreatment are discussed.