Social Welfare Policy and ServicesSOCW 410Fall 2014

The policy process

Technical Aspects of the Policy Process

• Public policy in the United States is made through a deliberative process – Involves the two bodies of elected officials

that make up a legislature

• There are several critical junctures in a proposal’s passage into legislation

• The federal budget process

Policy Analysis Framework

A Critical Analysis of the Policy Process

• The public policy process often proves frustrating for social activists

• The policy process consists of a series of discrete decisions

• Institutional conception of social welfare

• Residual conception of social welfare

• Bureaucratic & market rationality

The Policy Process

• Social Stratification– Differentiate groups with influence from

those lacking

• Marginalization– The governmental policy process poses

problems for administrators and practitioners

The Policy Process

• Legislation– Much public policy work is conducted by

federal legislators

– Lobbying and campaign contributions

– Social advocacy groups usually rely on volunteer lobbyists

The Policy Process

• Implementation– The fact that a policy has been enacted

does not necessarily mean it will be implemented

• Evaluation– Spawned a veritable industry in program

evaluation

Social Stratification

Social Insurance

Definition of Social Insurance

• Social insurance is the cornerstone of U.S. social welfare policy– Compelled to insure themselves

• Unlike Social Security, public assistance programs are subject to means tests – And are based entirely on need

The Background of Social Insurance

• The first old-age insurance program was introduced in Germany in 1889

• Social Security Act of 1935– Repeatedly modified, almost always in the

direction of increased coverage

The Financial Organization of Social Insurance

• Social insurance is relatively straightforward

• Social Security and Medicare taxes are divided among several trust funds

• The trust funds are governed by a board of trustees

• Surplus

Key Social Insurance Programs

• OASDI– Combination of Old-Age and Survivors Insurance

(OASI) & Disability Insurance (DI)

– Cost-of-living adjustments (COLAs)

• Unemployment Insurance– The Unemployment Insurance System and Benefits

• Workers’ Compensation– Began in 1911 in Wisconsin and New Jersey

– WC programs are problematic in several ways

The Social Security Dilemma

• Was long perceived by policy analysts and legislators as the third rail of politics

• Arguments against the Current Social Security System– Social Security is fueling intergenerational

tensions

The Social Security Dilemma

• Arguments for the Current Social Security System– Social Security is a special kind of

“investment”– Social Security in Trouble

• The Long-Term Prospects for Social Security

Conclusion• The U.S. Social Security stands out as

one of the best in the world• Social insurance programs are a mainstay

of the American social welfare state• Social insurance programs represent a

major source of security – For elderly Americans & present-day workers

Public assistance programs

Assumptions and Myths about Public Assistance

• American attitudes toward public assistance – Characterized as a mixture of compassion

and hostility

• Myths

• Facts

Aid to Families with Dependent Children

• AFDC was arguably the most controversial program in the U.S. welfare system

• The requirement for receiving AFDC

• One notorious chapter in AFDC history involved the man-in-the-house rule

Aid to Families with Dependent Children

• The Personal Responsibility and Work Opportunity Reconciliation Act of 1996– Emergency Assistance Program– Entitlement– Participation rate

Aid to Families with Dependent Children

• The American Recovery and Reinvestment Act of 2009– Passed in 2009 to strengthen safety net

programs such as TANF and SNAP

• Has the PRWORA Worked?– By 2000, Democrats and Republicans had

pronounced the PRWORA a raging success

Supplemental Security Income (SSI)

• Designed to provide cash assistance to the elderly and to disabled poor individuals

• Two groups of SSI recipients that have shown dramatic growth in their numbers – Children with disabilities– Adults with disabilities related to drug

addiction and alcoholism

General Assistance

• Most states limit GA eligibility to the severely poor, without children

• Some states fund GA programs – But delegate administration to counties,

municipalities, or towns

Trends and Issues in PublicAssistance

• The responsibility of states to care for their poor is not new

• Transforming Public Assistance Policy into Labor Policy– AFDC had been a sore spot for

conservatives since its inception

Trends and Issues in PublicAssistance

– The PRWORA was passed in a period of robust economic growth

• Teenage Pregnancy– Has been strongly associated with public

assistance and welfare dependency– Ten percent of all U.S. births in 2009 were

to mothers under the age of 20

Trends and Issues in PublicAssistance

• Welfare Behaviorism– Behavioral Poverty– Personal and Parental Responsibility

• Welfare to Work– Workfare

The Evolution of Public Assistance

• There are myriad ways to provide social assistance to the poor

• Recipients of public assistance programs – Fare less well than as those covered under

the social insurances

Conclusion

• The U.S. welfare system has dramatically transformed over the past 20 years

• The conversion of public assistance policy into labor policy

• Privatized social services

Health care policy

Why Is Health Care Important?

•Both wellness and sickness care are important to individual lives

•The health care sector has continued to grow, while most other parts of the economy stalled

•It is a source of innovation—pharmaceuticals, technology, and systems

(Continued)

Why Is Health Care Important?

•Health care is one of the most important industries in the United States:• National health expenditures are almost

$2.5 trillion annually (2009)• It is 17.6% of GDP (2009)• It employs more than 14 million Americans

(2008)

(Continued)

•The division of labor between the public health system, which keeps people healthy, and the medical care system, which takes care of them when they are not

•The importance of institutions, such as hospitals

•Medical technology that fuels expansion•A dysfunctional financing and payment

system•Tension between the free market and

government control

Defining Characteristics of the U.S. Health Care System

•We spend too much•Quality of care is uneven•Too many people lack access to care

How Well Are We Doing? (Continued)

•Improving quality• Improving access and coverage•Slowing the growth of health care costs

Major Issues and Concerns

(Continued)

•Encouraging healthy behavior• Improving the public health care system•Improving coordination, transparency, and

accountability of local health care systems

Major Issues and Concerns (Continued)

•Consumers, patients, and taxpayers•Health care professionals and institutions•Pharmaceutical, insurance, and other for-

profit companies•Payers and organizations that regulate or

accredit health care organizations

Stakeholders

• Department of Health and Human Services

• Social Security Administration

• Department of Labor• Department of Homeland

Security• Department of Defense• Department of Veterans

Affairs• Department of Agriculture

Many Government Agencies Are Involved in Health and Safety

• Department of Justice• Department of Energy• Department of Housing and

Urban Development• Department of

Transportation• Department of Education• Department of Commerce• Environmental Protection

Agency

(Continued)

• National AIDS Policy Office• National Bipartisan

Commission on the Future of Medicare

• National Council on Disability

• Office of National Drug Control Policy

• Uniformed Services University for the Health Sciences

Many Government Agencies Are Involved in Health and Safety (Continued)

• State Department • Agency for International

Development (Global Health)

• U.S. Chemical Safety Board• Consumer Product Safety

Commission• Drug Enforcement

Administration• Medicare Payment Advisory

Commission

Where You Live Matters

FIGURE 1A.7Achieving long and healthy lives.Source: McCarthy, D., How, S.K.H., Schoen, C., Cantor, J.C., & Belloff, D. (2009). Aiming higher: Results from a state scorecard on health system performance, 2009. Retrieved September 9, 2010, from http://www.commonwealthfund.org/Content/Charts/Report/Aiming-Higher-2009-Results-from-a-State-Scorecard-on-Health-System-Performance/State-Ranking-on-Health-Lives-Dimension.aspx. Reprinted with permission.

The Uninsured

• Health care in the United States is marked by several contradictions

• More likely than the privately insured to not receive needed medical care

The Organization of Medical Services

• Most health care costs in the United States are paid for by: – Private insurers, public plans, and the

direct public provision of health care

• Major components of medical services in the United States

•Historical developments: Increasing costs and growing influence of hospitals

•The rise of employee-sponsored health insurance (1940s)

Government as Payer

(Continued)

• Enactment of Medicare and Medicaid (1960s)

• The Clinton failure and state reforms (1990s)

• The Patient Protection and Affordable Care Act

(2010)

Government as Payer (Continued)

Major Public Health Programs: Medicare, Medicaid, and S-CHIP

• Health care spending is the 2nd fastest-growing component of the federal budget

• Medicare– Critics charge that the MMA– Gaps in Medicare Coverage– Reimbursements to Providers

Major Public Health Programs: Medicare, Medicaid, and S-CHIP

• Medicaid– Medicaid is a federal/state program– The medically needy

• The Children’s Health Insurance Program (CHIP)– State Children’s Health Insurance Program

(S-CHIP)

The Tobacco Settlement

• Public policy is occasionally made by the court system rather than the legislature

• 600-page Master Settlement Agreement– Requiring them to pay $206 billion to 46

states over a 25-year period

• Australian Parliament passed a “Plain Packaging” bill

The Health Care Crisis

• Health care in the United States is plagued with problems such as: – Eroding coverage, rising and shifting costs,

• And an increasing number of anxious citizens fearful about getting and keeping health insurance

The Health Care Crisis

• Overview of U.S. Health Care Expenditures

• U.S. Health Care in International Perspective

Explaining the High Cost of U.S. Health Care

• Some factors that attribute for the enormous cost of U.S. health care system

• Hospital Costs

• Physicians’ Salaries

• The Pharmaceutical Industry

Cutting Health Care Costs

• There are two aspects to cutting health care costs– Cutting costs for governmental health care

programs; – Lowering health care costs in:

• Insurance, physician, pharmaceutical and hospital sectors

Cutting Health Care Costs

• Managed Care– Managed care plans generally gatekeep

the access to specialists for consumers– Managed care companies are boxed in to

a degree

Cutting Health Care Costs

• The Underinsured– The U.S. medical system provides high

quality care for most people…. • In the upper and upper-middle classes

Reforming U.S. Health Care

• The American health care system is partly driven by ideological values

• National Health Service

• National Health Insurance– Single-Payer System

• Incremental Reform

Reforming U.S. Health Care

• The Patient Protection and Affordable Care Act (P.L. 111-148)– Enrollment and Employer Requirements– Cost and Funding– Health Insurance Exchanges (HIE)– Subsidies

Reforming U.S. Health Care

– Regulations of the Health Insurance Industry

– Public Health– Medicare– Medicaid– Abortion

Comparative Analysis: Health Care in Canada, UK, & Australia

• The Canadian Health Care System– Public Administration– Comprehensiveness– Universality– Portability– Accessibility– Freedom of Choice

Comparative Analysis: Health Care in Canada, UK, & Australia

• The United Kingdom’s National Health Service– The NHS is currently the world’s largest

publicly-funded health service

• The Australian Health Care System– A hybrid public–private system

Conclusion

• The American health care system raises important questions

• The United States is one of the few industrialized countries without: – A universal health care system

Quiz Questions

• The government-provided healthcare program for the elderly is known as: – Medicaid– Affordable Care Act– Medicare– Blue Cross

Quiz Question

• When a third-party insurance company pays medical providers instead of consumers paying directly: – Consumer demand for health care rises– Out-of-pocket costs to the consumer go up– Consumers more clearly understand the

true cost of healthcare– The supply of healthcare falls

Quiz Question

• Health spending is a growing share of our economy because:– Aging population and rising costs– No costs is too small for a loved one– Technology is expensive but improves care– All of the above

Mental Health and Substance Abuse

Mental Health Reform

• World War II

• Dr. Robert H. Felix

The Community Mental Health Centers Acts

• Community Mental Health Centers (CMHC) Act – Passed by Congress and signed by

President Kennedy on October 31, 1963

• Transferring mental health care from the state hospital to the community

Deinstitutionalization

• By the end of the 1990s:– 93% of state psychiatric beds that had

existed in 1955 were lost to deinstitutionalization

• Effect on institutional care for patients with mental impairments

The Revolving Door

• Of the 5,000 residents of homes, 946 had died between 1995 and 2000

• During the 1990s: 350 incidents of theft, abuse, neglect, & molestation of residents – Not a single fine had been levied against

the companies that operated the group homes

The Psychopharmacological Scandal

• Psychotropic medication became a routine form of treatment

• Desperate former mental hospital patients turned to petty crime to gain income

• The ascendance of the biomedical model• Side effects attributed to SSRIs

Children’s Mental Health

• The FDA does not require RTCs for medication – Unless it is specifically intended for

children

• Off-label prescriptions for children

• 80 percent increase in autism during the previous decade

Mental Health and Substance Abuse Funding

• Since 1981, all mental health expenditures have been in block grants to states

• Static funding has prompted innovation in service delivery– Provided the rationale for subsidizing

private treatment innovations in substance abuse

Parity for Mental Health Care

• Congress agreed on legislation establishing parity for mental health care

• May have marked the end of the downsizing of mental health care– Yet much remained to be done

Post-Traumatic Stress Disorder

• A decade of war in Iraq and Afghanistan

• Not only were mental health disorders among returning soldiers delayed– But they were more prevalent among

reservists

Substance Abuse

• Mental health services are often associated with substance abuse

• Interaction of emotional difficulties, alcoholism, and substance abuse

Substance Abuse

• Alcohol Abuse– Americans steadily increased their

consumption of alcohol • From the end of World War II until the 1980s• Fetal alcohol syndrome

Substance Abuse

• Drug Abuse– The prevalence of drug abuse is more

difficult to ascertain– Types of illegal substances vary

considerably– The federal response to illicit drug use– Intervention strategies focus on treatment

Policy Analysis Notes

• Community Mental Health Centers Act

• Omnibus Budget and Reconciliation Act

Policy Analysis Notes

• Mental Health Parity Act

• America’s Law Enforcement and Mental Health Project Act

Conclusion

• Mental health and substance abuse policies have been complex

• Should responsibility for the aberrant rest with the federal government or the states?

• Should the focus be on treatment or interdiction?

Criminal Justice

Prison State Video Notes

• What are the mental health problems?

• What are the substance use problems?

• What are the crimes?

History of U.S. Criminal Justice

• Faith in social science that originated in the West in the eighteenth century

• Modern criminology dates from the Age of Enlightenment in the eighteenth century

• Early American colonists imported traditional European thinking about crime

The Criminal Justice System

• The U.S. criminal justice system is similar to education and mental health programs– States & localities provide a larger portion of

services than the federal government

• The last decades of the twentieth century witnessed a boom in prison construction

Juvenile Justice• Juvenile justice is a significant feature of U.S.

criminal justice

• New York City House of Refuge

• Massachusetts Division of Youth Services

• Incarceration as the intervention of choice• Boot camp

The New Jim Crow

• Race and ethnicity have been fundamental to understanding criminal justice

• Association between incarceration, social disadvantage & high school drop outs

• Gang involvement

The War on Drugs

• The deterioration of inner cities

• Government interdiction of supplies, aimed at eliminating the substance

• Treatment programs deployed to diminish the demand for illegal drugs

• The social consequence of the arrest and incarceration

The Underclass and “Moral Poverty”

• 45% of prisoners were on probation/parole when they committed their latest offense– In 1991

• The conservative prescription for moral poverty

• The evolution of liberal policies that divert youth from delinquency

Legalization of Drugs

• Drug legalization had been a standard demand among Libertarians

• Momentum toward legalizing drugs reached its peak during the mid-1980s

• Fair Sentencing Act, signed by President Obama in 2010

The “New Penology”• The public was growing increasingly intolerant

of crime

• Although crime has fallen, incarceration rates remain high

• Innocence Project

• Costly prison system

Conclusion

• Advocates continue to press for reform

• Some reformers have proposed more humane facilities for inmates

• The Karnes County Civil Detention Center

• Humanizing corrections