Showing papers by "Urban Institute published in 1996"

Excess Mortality among Blacks and Whites in the United States

Abstract: Background Although the general relations between race, socioeconomic status, and mortality in the United States are well known, specific patterns of excess mortality are not well understood. Methods Using standard demographic techniques, we analyzed death certificates and census data and made sex-specific population-level estimates of the 1990 death rates for people 15 to 64 years of age. We studied mortality among blacks in selected areas of New York City, Detroit, Los Angeles, and Alabama (in one area of persistent poverty and one higher-income area each) and among whites in areas of New York City, metropolitan Detroit, Kentucky, and Alabama (one area of poverty and one higher-income area each). Sixteen areas were studied in all. Results When they were compared with the nationwide age-standardized annual death rate for whites, the death rates for both sexes in each of the poverty areas were excessive, especially among blacks (standardized mortality ratios for men and women in Harlem, 4.11 and 3.38; in ...

Age Discrimination, Job Separation, and Employment Status of Older Workers: Evidence from Self-Reports

Abstract: This paper explores the prevalence and consequences of age discrimination in the workplace by analyzing self-reports of discrimination by respondents in the National Longitudinal Survey of Older Men. Age discrimination was reported in seven percent of our cases, during the period 1966-1980. Workers with positive reports were much more likely to separate from their employer and less likely to remain employed than workers who report no age discrimination. The estimated effect of reported discrimination remains large and significant even when controlling for the existence of mandatory retirement provisions on the current job. These findings are generally robust to numerous attempts to correct the estimates for the inherent limitations of self-reported data, particularly the potential heterogeneity bias that arises from differences in the propensity to report discrimination, and the possibility that discrimination is reported in response to other negative labor market outcomes.

The effects of medicaid expansions on insurance coverage of children

Abstract: In the Winter 1995 issue of The Future of Children, the Child Indicators article examined recent trends in health insurance coverage for children. A major conclusion of that article was that the proportion of children covered by private, employment-based health insurance has been declining in recent years while changes in the rules for eligibility for Medicaid have made that program increasingly important for children. Nearly eight million more children were covered by Medicaid in 1993 than in 1988, largely as a result of the eligibility expansions. However, the number of uninsured children grew by about one million during that same period.

The impact of diagnostic testing on therapeutic interventions.

Abstract: Objective. —To gain insight into the usefulness of managing the earlier phase of decision making, we examined the relationship between selected diagnostic tests and the therapeutic interventions they might trigger. Design. —Medicare's National Claims History and Part B files were used to obtain summary information on 100% of all physician claims submitted from 1987 through 1993. We regressed the annual rates of selected therapeutic interventions on selected diagnostic tests, which had been previously paired based on the clinical expectation that the test might drive subsequent intervention. Population and Setting. —These data represent the physician services received by approximately 30 million elderly Americans in each of 7 years. Main Outcome Measure.—Coefficient of determination (R 2 ). Results. —The annual rate for the diagnostic tests increased rapidly during the period (range, 1.4- to 3.0-fold increase) and accounted for the bulk of the variance in therapeutic intervention rates (R 2 >0.80, P Conclusion. —There has been a substantial increase in diagnostic testing in the United States that closely tracked the increase of clinically relevant downstream procedures. Managing diagnostic testing could be an important strategy for controlling the increase of therapeutic interventions. ( JAMA . 1996;275:1189-1191)

YOUTH AT RISK: Definitions and Implications for Service Delivery

Abstract: The literature on adolescent risk is reviewed, a model of risk that emphasizes risk antecedents and markers is proposed, and an overview is presented of an emergency service delivery strategy that integrates services, emphasizes interagency coordination, and addresses the full range of service needs for youth at risk. Highlights of programs currently in operation are described.

Admission Criteria and Immigrant Earnings Profiles

Abstract: This study examines the effect of legal immigration admissions criteria on earnings profiles of immigrants in the United States. It is based on 1980 census data matched to Immigration and Naturalization Service information. The authors examine the theoretical and empirical effects on immigrants' earnings on the basis of the criterion for admission?either occupational skills or kinship. The study focuses on immigrants' entire life-cycle earnings after entering the United States rather than solely on their initial or average earnings.

Self-Insured Employer Health Plans: Prevalence, Profile, Provisions, and Premiums

Abstract: Data from three recent surveys indicate that about 40 percent of workers with employment-based health insurance are enrolled in plans that their employers self-insure. Despite the conside...

Homeownership counseling performance: How can it be measured?

Abstract: Homeownership counseling encompasses several educational activities. Early approaches focused on reducing the risk of default and foreclosure among participants in government‐assisted mortgage programs, but more recent approaches have focused on increasing homeownership opportunities among low‐income and minority households. Unfortunately, little is known about the effectiveness of these approaches in terms of the number of new homeowners and the mitigation of default risk. To address that gap, this article presents a theoretical and methodological framework to evaluate counseling efforts. A successful counseling program is defined as one that assists a household with a low long‐term probability of ownership in buying a home and reducing its default risk. We concede that the methodological requirements for evaluating counseling are somewhat restrictive. However, if we establish an evaluation procedure using these goals as a framework, we can more accurately determine the effects of counseling on ...

Trends in the relationship between breastfeeding and postpartum employment in the United States.

Abstract: It is widely assumed that employment and breastfeeding are relatively incompatible behaviors in the United States; yet recently both the incidence of breastfeeding and the incidence of postpartum employment increased. This paper examines the relationship between these trends from 1968–86 using data from the National Surveys of Family Growth. I find that these trends result from increases in the likelihood that a woman engages in both breastfeeding and postpartum employment. There has been an increase over time in the incidence and duration of women concurrently breastfeeding and working. However, the majority of employed women did not concurrently breastfeed, suggesting that conflicts between these behaviors still exist.

Can Medicaid Long-term Care Expenditures for the Elderly Be Reduced?

Abstract: During 1995 and 1996 Congress debated numerous proposals that would dramatically reduce the rate of growth in Medicaid spending, initiatives that inevitably would affect long-term care for the elderly. There are three broad strategies that states might use to control long-term care spending-bring more private resources into the long-term care system to offset Medicaid's expenditures, reform the delivery system so that care can be provided more cheaply, and reduce Medicaid eligibility, reimbursement, and service coverage. Based on the available research evidence, there is little evidence to suggest that large savings are possible without adversely affecting beneficiaries' eligibility, access to services, and quality of care received.

Defensive Medicine and Tort Reform: New Evidence in an Old Bottle

Abstract: Quantitative analysis of medical liability?s influence on medical practice is a small but growing field, noted this literature review and commentary. The three papers on defensive medicine in this journal issue illustrated three possible analytic approaches: case study of technological diffusion, survey of physician responses to detailed clinical scenarios, and multivariate analysis of relation of physicians' scenario responses to objective liability experience. The papers also offered a good picture of the state of the art: Many difficulties hamper research in this area, and these papers like others offer considerable illumination but leave much uncovered. Defensive medicine surely exists, but its impacts on health care spending and access are unclear. The most important lessons for public policy are that tort reform may be necessary but not sufficient to reduce the problems associated with defensive medicine and that the major malpractice problem continues to be malpractice. (Journal of Health Politics, Policy and Law 1996 Summer; 22(5); 1133-1189).

The Russian Dacha phenomenon

Abstract: This paper begins to fill the void of information about dachas in Russia by drawing on household surveys conducted in seven cities between November 1993 and January 1994. Based on these data, it appears that dachas are a common phenomenon — about one urban family in four has one, with the incidence fairly stable across cities. At the same time, these dachas range from very modest, simple structures to the elegant country house, with the clear majority at the more basic end of the spectrum. While only a small share of dachas are now used during the winter, nearly half of all owners of seasonal‐use dachas stated they definitely want to improve their unit for winter use. It seems possible that as upgrading proceeds some dachas will be converted to add to the permanent housing stock.

A Detailed Comparison of Physician Services for the Elderly in the United States and Canada

Abstract: The goal of this report was to assess the relative volume and price of physician services in Canada and the United States through a comparative analysis of 1992 claims data from Canadian provincial ministries of health and from the U.S. Health Care Financing Administration. The study groups consisted of all the elderly in the three largest Canadian provinces and a 1 percent random sample of U.S. elderly Medicare beneficiaries. Patterns of use of physician services and procedures are described, and several possible explanations for differences between the patterns in the United States and Canada are suggested.

Choice characteristics and parents' child-care decisions:

Abstract: Choice models are a key tool of empirically oriented rational choice researchers. However, most researchers do not have the information they need to adequately test their hypotheses and rely solely on individual characteristics of the choosers. The lack of information on the options and constraints parents face may lead researchers to conclude that choices are not rational rather than to question whether they have the appropriate data. This issue is particularly important for researchers interested in modeling child-care choice, since the characteristics of care are more amenable to policy intervention than the characteristics of persons. This paper estimates models of choice of child-care arrangement that include measures of price, quality and availability obtained directly from parents in the National Child Care Survey of 1990. This paper compares alternative estimates of the associations of these characteristics with mode choice. Adding care characteristics to models with individual characteristics imp...

What Medicare has meant to older Americans.

Abstract: In marking Medicare's 30th year in operation, it is fitting to focus on the program's successes. The fiscal pressures facing Medicare on both its own financing base and that of the Federal Government as a whole, and the rapid changes occurring elsewhere in the health care system, have led to a raft of criticisms of the program in recent years. Although Medicare could certainly be improved, pausing to reflect on the positive aspects of the program can offer some balance to the current debate on Medicare's future. Medicare is the largest public health program in the United States, providing the major source of insurance for the acute medical care needs of elderly and disabled persons. Its administrative costs are low, and it is popular with both its beneficiaries and the population as a whole. It has delivered on its promises. The success of Medicare from the perspective of older Americans can be summarized in four broad areas.

Privatized housing and the development of condominiums in central and eastern europe: the cases of poland, hungary, slovakia, and romania

Abstract: This paper looks at the housing sector reform in Central and Eastern Europe and examines the progress to date in housing privatization and policies aimed at improving the management and condition of the existing housing stock through the establishment and operation of the condominium form of ownership. The paper compares and analyzes approaches taken in four countries with regard to four issues: (I) the legal framework and implementation strategies; (2) the role of local government housing strategies in supporting the development of viable condominium associations; (3) property management of privatized housing; and (4) financing rehabilitation and capital repair projects for condominiums. Findings include the need for a clear legal framework, competition in the property management market, more supportive local government policies, and public sector support in tackling rehabilitation finance issues.

Medicaid coverage of maternity care for aliens in California.

Abstract: The quantity and cost-effectiveness of prenatal care is a critical reproductive health issue as federal and state legislators consider reducing publicly funded services to aliens. An analysis of data from medi-Cal, California's Medicaid program, shows that undocumented and legalized aliens who qualified for coverage under the provisions of federal legislation or the state's expansion of eligibility criteria accounted for 45% of deliveries financed by Medi-Cal in 1991; outlays for these deliveries are estimated at less than 2% of all Medi-Cal payments for that year. Most of these women also received prenatal care covered by Medi-Cal, but more than half were not enrolled in the program until after the first trimester of pregnancy (and thus may not have received adequate prenatal care). Alien women were enrolled for an average of 5-6 months of their pregnancy, whereas nonalien women who qualified for coverage were enrolled for about seven months. California's Proposition 187 would eliminate funding for prenatal care for undocumented aliens, but public outlays for labor and delivery could grow as a result of an increase in poor birth outcomes.

The impact of practicing in multiple hospitals on physician profiles.

Abstract: Although physicians are all too familiar with the psychologic impact of having multiple responsibilities, the associated impact on practice styles has not been examined systematically. To provide some data on the effects of "work dispersion," we examined the hypothesis that the inpatient resource use of physicians would rise with the number of hospitals in which they work. Data for 1991 from Medicare's National Claims History File were used to profile a sample of attending physicians (n = 33,756) in seven states. The attending physician "profile" was the case mix-adjusted relative value of all physician services (regardless of who delivered them) that were delivered during each patient's hospital stay. Relative value was measured in relative value units, used by Medicare in determining physician payments. The authors then categorized physicians in terms of the number of hospitals to which they admitted patients. Physician profiles were adjusted further to control for geography, physician specialty, and characteristics of the physician's primary (ie, most used) hospital. One third of the physicians in the sample had admissions to more than one hospital. Physicians working in one hospital had inpatient practice profiles 2.1% below the sample mean. Additional hospital affiliations were associated with progressively higher profiles: two hospitals, 2.3% above the mean; three hospitals, 4.5% above; four hospitals, 8.2% above; and five or more hospitals, 11.5% above (all P < 0.01). The practice of medicine in more than one hospital is associated with higher inpatient profiles and shows a dose-response relationship. Physicians and policy makers will need to consider carefully whether there are any associated benefits to justify the increased cost.

Residential Mobility in Moscow During the Transition

Abstract: This paper explores aspects of the evolving pattern of residential mobility in Moscow for the period 1992-1994. A three-year longitudinal survey of about 2,200 dwelling units served as a data source. It tested the hypothesis that the burst in mobility rates between 1992 and 1993 was not a one-time phenomenon; examines the composition of movers; tests the hypothesis that mobility is concentrated among market movers; explores the change in housing conditions achieved by relocating; and estimates simple models of the probability of moving on a market basis or of obtaining housing through waiting list procedures.

Real estate markets in urban russia

Abstract: This paper provides a framework for analyzing the Russian real estate sector during the economy's transition to a market system, discusses the results that have been achieved, and offers suggestions for improving the situation. A stock/flow model of the real estate sector is used as the primary framework to identify the factors that are retarding the transition of the Russian real estate sector to a market system. The current state of the Russian real estate sector is illustrated with data for the city of St. Petersburg, as well as other Russian cities. Policy proposals are provided to accelerate the transition to a market system, to stimulate real estate production, and to create a real estate finance system. The ideas developed here may also be relevant to other markets in Russia and to other transition economies.

Preferred Provider Organizations and Physician Fees

Abstract: Preferred provider organizations (PPOs) represent a form of managed care in which providers agree to accept discounted fees in exchange for the expectation that their patient volume will increase or at least be maintained. Managed care plans that rely on discounted fee-for-service (FFS) payments have increased from about 10 plans in 1981 to over 700 plans in 1994. In this study, we document levels of discounts achieved by two large national insurers and discuss how the size of the discount varies by type of service and how the discounted rates relate to Medicare fees. Our results show that, despite achieving large discounts (approximately 10-20 percent) relative to their indemnity plans, the two nationwide PPOs studied here pay at rates substantially above Medicare levels.

Housing Demand in a Transitional Market: Moscow

Abstract: This report uses data collected for Moscow several years after the legalization of market-based housing transfers to test for evidence of market behavior. A 1994 survey of Moscow households was used to compare characteristics of two groups of families: those that have privatized their units or engaged in housing market transfers and those families that have maintained state ownership of their residences. Next, recent movers who obtained their new units through market purchases and exchanges were studied to estimate a conventional housing demand function. The use of per-capita living space as a proxy for market value is also evaluated.

A Note on Enterprise Housing Divestiture in the Russian Federation

Abstract: To encourage enterprise privatization and improve enterprise efficiency, the Russian Federation government mandated that local governments assume financial and management responsibility for the housing stock of privatizing enterprises. Despite the mandate, the process of enterprise housing divestiture has proceeded relatively slowly. This paper overviews the legal basis for enterprise housing divestiture and discusses the fiscal impact of divestiture on enterprises and local government budgets. We collected data in three Russian cities: Petrozavodsk, Ryazan, and Vladimir, during the fall of 1995. We conclude that, although the financial benefits to enterprises may be quite significant, the cost of enterprise housing divestiture will impose a significant financial burden on local governments. This conclusion explains the hesitancy of many local governments, despite the federal government mandate, to accept the housing stock of privatizing enterprises.

Medicaid and Service Use Among Homeless Adults

Abstract: Expansions of Medicaid eligibility intend to improve access to care, and to shift care from emergency rooms and inpatient hospital care to more appropriate sites. We examine the effect of Medicaid recipiency on the level and site of medical service utilization using data from 1985 and 1987 surveys of New York City homeless single men and women. Simple regressions of Medicaid on the use of health services among homeless adults indicate that Medicaid significantly increases the likelihood that these individuals receive services, especially emergency and inpatient hospital services. We test this result in further analyses that control for health status, use instrumental variables procedures, and examine differences between a similar population in 1985 and 1987. These analyses suggest that Medicaid neither increases nor diminishes access to emergency rooms. We find some evidence that suggests that Medicaid does improve access to non-hospital medical care.

The measurement of physician work and alternative uses of the resource based relative value scale.

Abstract: On January 1, 1992, the Medicare program implemented a new payment system for physician services based on the Resource Based Relative Value Scale (RBRVS). The RBRVS has been widely accepted as a rational and systematic approach to measuring the resource costs associated with physician services. In addition to deriving physician payment rates, the RBRVS provides a useful metric that allows the measurement and comparison of provider utilization rates and productivity across physicians performing a varied mix of services. In this study we describe the measurement of physician work, discuss alternative ways in which work values can be used to monitor physician service utilization (e.g., profiling physician practice patterns), measure physician productivity, and determine physician compensation.

Race Differences in Labor Force Attachment and Disability Status

Abstract: We use the first wave of the Health and Retirement Survey to study the effect of health on the labor force activity of Black and White men and women in their 50s. The evidence we present confirms the notion that health is an extremely important determinant of early labor force exit. Our estimates suggest that health differences between Blacks and Whites can account for most of the racial gap in labor force attachment for men. For women, where participation rates are comparable, our estimates imply that Black women would be substantially more likely to work than White women were it not for the marked health differences. We also find for both men and women that poor health has a substantially larger effect on labor force behavior for Blacks. The evidence suggests that these differences result from Black/White differences in access to the resources necessary to retire.