Unit 3
1) MOE – maintenance of effort
In terms of PRWORA states must continue to spend at least 80% of what they spent in 1994 on public assistance in order to receive their full block grant from the federal government
2) PRWORA – personal responsibility work opportunity reconciliation act of 1996
Created devolution via federal money to the states that would control programs via block grants as JOBS, AFDC, and emergency assistance programs all collapsed into TANF
Disentitlement shifted all into federal welfare programs
3) Shifting public assistance into labor policy rewards employers of low wage workers
Low pay, no benefits/healthcare/retirement are replaced by EITC, Medicaid, and SNAP
Punish low wage workers forced to remain in dead end jobs or take dead end jobs
4) The four goals of PRWORA – Personal Responsibility Work Opportunity Reconciliation Act of 1996
Money for children in their own home or a relative’s home
Promote self sufficiency – end welfare dependency
Reduce out of wedlock births
Growth and maintenance of two parent households
5) Deductible: the amount you pay out of pocket for medical service like MRI or x-ray
Usually higher deductible plans have a lower premium
6) Insurance premium: amount paid usually per month or per pay for healthcare coverage
For workers can be paid by employee only or shared with employer
7) Copay: amount paid for a specific service like PCP (primary care physician) visit when your deductible is met or if your plan provides this before the deductible is met
8) Medicare
a. HI – hospital insurance
b. Supplemental – lab, PT, OT, outpatient mental health, drug and alcohol
c. Medigap or Medicare Advantage
d. Prescription drug benefit
9) 4 large gaps in Medicaid
a. Low eligibility levels
b. States refuse many of the Medicaid options available
c. Gaps for people that are elderly and gaps for people that have a disability
d. Poor single individuals and poor childless couples
10) Capitation: method of payment in which a provider is paid a fixed amount per person served regardless of the actual number or the nature of the services delivered
11) Some of the leading cost drivers that increase healthcare cost in the U.S. are technology, prescription drugs, lawsuits, and uncompensated care
12) Dr. Felix produced literature and critiques of contemporary institutional care. His three decades of mental hygiene division public service and his establishment of political networks and contacts were used to establish the National Institute Mental Health and Mental Health Act of 1946
13) Community Mental Health Center Act of 1963 – funding for construction cost only
Community Mental Health Center Act of 1965 – funding now for staffing, brought federal regulations and standards, treatment in the community over warehousing people with mental health issues, catchment areas and alternatives to state hospital institutions
14) Categorical grants used in a capitation mental health funding model, flexible funds in a common fund for the following
Medicaid
SSI
SNAP
Local funding
Planning and Coordination mental health plan is formulated negotiate costs for services or contracts, contract monitoring/oversite and innovative programming
ID heavy users find a way to reduce their cost with more effective approaches to treatment
15) Block grants more conservative ideological approach to funding human services, smaller funding blocks are given to lower levels of government to manage with some flexibility in spending for a specific purpose
16) CAPTA – Child Abuse Prevention and Treatment Act of 1974
A model for all states to adopt on child protective services; does 4 things
- Defines child abuse and neglect
- Contains methods for reporting and investigating of child abuse and neglect
- Provides immunity for reporters of suspected abuse and neglect
- Provides prevention and public education to reduce abuse and neglect
17) Dr. Henry Kempe identified non-accidental injuries to children as battered child syndrome; in 1962 first published his findings in JAMA; helped change norms and values and societal views on child abuse in the U.S.
18) Adoption Assistance and Child Welfare Act of 1980
New emphasis on permanency planning brought about 20% decrease in foster care placements
1971 – 330,400 foster care placements
1982 – 262, 000 foster care placements
Rapid return of children proved to be difficult and increased the need for CPS
Child cannot be placed with adoptive parents without provision of adoption assistance
19) 2008 – President George W. Bush signs Fostering Connections to Success and Increasing Adoptions Act
Allowing for guardianship payments (kinship care in PA)
Extension of benefits until age 21
20) WIC is a federal grant program not an entitlement
21) More than half of all Black men without a high school diploma are incarcerated at some point in their lives
22) Kids for Cash scandal, Luzerne County PA
Judge Ciavarella and Judge Conahan imprisoned juveniles for very minor offences in a private run detention center in exchange for $2.8 million in kickbacks
23) U.S. has highest incarceration rate of all industrialized nations – 738 per 100,000 people
24) Geriatric inmates and women inmates are most expensive to incarcerate due to healthcare costs
25) McKinney Vento Homeless Assistance Act of 1987 created 20+ programs for housing administered by 9 different federal agencies
26) Underwater or Upside down Mortgage – value of a house or property falls below what you owe on the loan
Options – stay/stick it out; walk away/loose it all; try to renegotiate or refinance
27) Gentrification – urban renewal fueled by investment moves young white collar workers in causing displacement of poor aging often nonwhite populations from center cities
28) Housing bubble/sub-prime mortgage crisis – changes in traditional banking model created risky financial practices leading to incredible levels of loan default and economic crisis in the U.S. and the world
29) According to HUD – U.S. Department of Housing and Urban Development for affordable is 30% of your post tax income including utilities
30) Red lining – discriminatory practice in banking that limits housing or property ownership opportunities
Example of institutional oppression where loans are not issued for specific locations
31) Housing bubble/Great Recession – September 2008-2009 brought on by housing market crash fueled by risky loans being issued led to total losses of $3.4 trillion in U.S. real estate value, $7.4 trillion in stock wealth loss, and collapse of major banks
32) CAFO – Concentrated Animal Feeding Operation
Agricultural enterprise usually involving thousands of animals or tens of thousands of birds oversight by multiple government agencies
County Conservation District, PA Department of Ag, DEP, USEPA
33) Fracking: deep drilling for natural gas and oil happening in PA since about 2006; creating energy and jobs as well as environmental issues and concerns
3 + 1 major public assistance programs
SNAP
TANF
GA
+ 1 = SSI
Republican Revolution 1994
Contract w/ America / Newt Gingrich
AFDC – aid to families with dependent children
Most controversial public welfare program in US history
1935 – Social Security Act includes ADC (aid to dependent children)
1950 – Caregiver made eligible (usually a woman)
1961 – AFDC UP (unemployed parent) 25 states participated (1990 mandatory)
1968 – “Man of the House Rule” US supreme court strikes it down
1972 – AFDC divided into; Income Maintenance and Social Services
1988 – Family Support Act of JOBS Program
Contract w/ America (10 bills moved in 100 days)
The FISCAL Responsibility Act – a balanced budget/tax limitation amendment and line-item veto power for the president
The Taking Back Our Streets Act – focus on longer prison sentences; strengthen the death penalty; cut previous crime bill’s social spending and use the money for more prison construction
The Personal Responsibility Act – prohibit welfare benefits to minor mothers and deny increased benefits for additional children born to mothers on welfare; cut spending for welfare programs; and end benefits after two years, with provisions for work requirements
The Family Reinforcement Act – bolster enforcement of child support; provide tax incentives for adoption; strengthen rights of parents in their children’s education; strengthen child pornography laws; and provide an elderly dependent care tax credit
The American Dream Restoration Act – provide a $500 per child tax credit; repeal marriage penalty in tax code
The National Security Restoration Act – prohibit U.N. commando f U.S. troops; increase defense spending, particularly on antimissile defenses
The Senior Citizens Fairness Act – raise the social security earnings limit; repeal 1993 tax increased on social security benefits
The Job Creation and Wage Enhancement Act
The Common Sense Legal Reform Act
The Citizen Legislature Act
PRWORA
Disentitlement of the poor
Disentitlement of legal immigrants
Time limited, no longer needs based
Failure to pay child support – loss of licenses (hunting/fishing)
Passage emboldens conservatives – look to privatize social security – see less money for private investment due to social security trust funds
States must submit plan to Department of HHS
Block grants
Maintenance of effort (MOE)
Restrictions
Diversion programs
Social workers in healthcare
NAWS code of ethics
Historic involvement
Diversity of social work degree
Interdisciplinary
Administration
Policymaking
Direct practice
Healthcare debate
Is healthcare a right or a privilege
Government insured healthcare
Medicare – care for those 65 and over or those with very specific medical diagnoses
Medicaid – provide aid for those who are financially disadvantaged
Actie military and VA coverage
Largest healthcare system in the world
Medicare
Senior – retirement benefit
Part A – 65+ #2 large social program (social security #1)
Inside the hospital
Programs Part B – (supplemental med insurance)
Outside of the hospital
Home health
Physical therapy
Occupational therapy
Part C – Medicare advantage/medigap
If you were on Traditional Medicare it was Parts A & B & medigap
Medigap not paid for by Medicare
Pay for medigap using a supplemental insurance or a Medicare advantage program
Need to go to someone in that network
Part D – drug prescription
Came in under George W. Bush (43rd U.S. President)
Medicaid (those in poverty)
Pre-1965 charity run
President Johnson 1965 – replaces all other programs
States set parameters payment/reimbursement
Largest healthcare cost is hospitalization
Uninsured
More likely to not receive care
Need hospitalization more for acute conditions (diabetes, pneumonia)
Receive routine care in ED
Children without coverage more likely to have developmental delays
Often put off seeking care
Financial complications of no coverage
Healthcare is the second fastest growing segment of the federal budget
The number one thing is debt service
Since 2010 deductibles have increased 67%
Tobacco Settlement – Judicial Branch Policy Setting
Policy made by Courts or Judiciary Branch
Started in 1994 when 7 Major Tobacco Companies testified before Congress – Nicotine was not addictive
1998 states’ Attorneys’ General in 46 states won the case-settlement for $206 billion over 25 years, then by formula as long as tobacco is sold in their states
CMS – centers for Medicare and Medicaid services
By 2028 we will be spending 6.8 trillion dollars on healthcare
S CHIP – children’s health insurance program
Below 200% of Federal Poverty Level to qualify
Each state receives matching payments
Created by Balanced Budget Amendment 1997
Funded 15% HIGHER rate than Medicaid
Preventative care reduces healthcare costs
2013 - $85 billion for uninsured care
Series new health issue – 20% decrease in household income
Healthcare…crisis
1997 to 2006 costs skyrocketed by $2 trillion
(entire combat phase of the Iraq War $3 trillion)
Biggest driver of cost – hospital bills (31.4% of all cost)
1965 – stay = $315
2007 – stay = $22,596 for 5 day stay
2002 cost up 9.5% or more than 5x rate of inflation
Healthcare players
Patients (insured/uninsured)
Insurance providers
Employers
Medical providers
Primary care
Specialist
Ancillary care (pt, ot, rt, x-ray, dietitians)
Home health and hospice/palliative medicine
Hospitals
Administrators
Billing
Records
Legal council
Pharma
Lobbyists
Government
Why is healthcare so expensive
Administrative cost
Technology
Drugs
Physicians pay
Lawsuits
Longer life for people that are ill/poor health
Medication costs to those individuals enrolled in Medicare Part D
Deductible
Initial coverage
Former coverage gap
Catastrophic benefit period
Cutting cost
DRG (diagnosis related group)
System pays only for the average length of a diagnosis
HMO – initial success, now not as much
Underinsured – high copay and deductible
LIFETIME CAPS (ACA removed)
VA uses buying power negotiation
Affordable Healthcare Act (ACA/Obamacare)
Pre-existing conditions
Lifetime Caps lifted
Children covered (age 26)
Donut Hole 2020
85% for Care not Bonuses
Insurance companies must put 85% of what they make back into care for people
Low-income subsidies
Medicaid expansion
Investments in healthcare
Build Back Better
Inflation Reduction Act 2022
Hits of the ACA
Website crashed out of the gate
Trump administration individual mandate penalty
Cost sharing subsidies stopped 2017
Invincibles least likely to get coverage
Veto 1854 of Dorothy Dix legislation
DSM – diagnostic and statistical manual
DSM I 1952 128 categories
DSM II 1968 193 categories
DSM III 1980 228 disorders
DSM IIIR 1987 265 disorders
DSM IV 1994 297 disorders
DSM IVTR 2000 383 disorders
DSM 5 2013 541 disorders
Court decisions
Buck vs. Bell
1927
Supreme Court hands down a ruling that leads to forced sterilization
65,000 people affected
“this person is feeble-minded and future offspring will pose a threat to society”
In place until 1942 by Skinner vs. Oklahoma
Wyatt vs. Stickney
1971
U.S. District Court in Alabama
It says state is required to provide inpatient care if the person requires it
Unfunded mandate – putting responsibility and cost onto the state but not providing funding to do so
State of Alabama refuses
Donaldson vs. O’Connor
1975
Supreme Court
State cannot confine anyone with a mental health issue that is not dangerous and can survive independently outside of the hospital
Basis/argument the states have to not provide treatment or spend a lot of money on mental health
Halderman vs. Pennhurst
1977
U.S. Third District Court
Institutionalized patients should be given “least restrictive” alternative
Dr. Robert H. Felix
Mental Health Act of 1946
NIMH – National Institute of Mental Health
Community Mental Health Centers Acts – 1963 & 1965
1963 – construction only
1965 – staffing
Demonopolize state’s role in mental health treatment – federal regulations
End “warehousing” of people with mental health diagnoses in inpatient settings
Establish Catchment Areas
NIMH Matching Grants (8-year periods) disadvantaged catchment areas
Medications 1970s – Haldol, Thorazine, Prolixin, Stelazine
Stabilize, side effects, decompensate
Panetti vs. Quarterman – U.S. Supreme Court 2007
You must have a rational understanding to be able to be executed by the State
Governor Tom Wolf institutes an executive order placing a moratorium on executions in PA, 13 Feb 2015
Deinstitutionalization
1955 to 1990 – 93% decrease in inpatient mental health beds in U.S.
Alan Stone – psychiatrist and Harvard Law Professor
“you have a right to be insane”
Static funding prompts changes
Categorical grants – multi program with capitation
Non-profit planning/coordination
Heavy users diverted to lower cost options
1979 – 691 Community Mental Health Centers in U.S.
1981 – All funding to Community Mental Health Centers STOPS
Rolled into block grants to the states (SAMHSA)
Providers of Last Resort
2000 – 283,800 inmates with mental health diagnosis
550,000 people on parole with mental health diagnosis
2003 – U.S. Prisons held 3x as many people with a mental health diagnosis than did inpatient psychiatric hospitals
Children’s mental health
2008 – 60% of all anti-psychotic medication given to children
“off label use” of adult medications
Randomized Clinical Trials (RCT)
Parity and Veterans
PTS (up 79.5%) and other illnesses on the rise with lengthy war
Parity…sort of…employers compliant, but restructuring benefits to make mental health treatment more difficult to access
2013 U.S. per-capita alcohol consumption
Alcohol used 66% of population 33% of population
Spirits 1.5 gallons 0 gallons
Wine 2.3 gallons 0 gallons
Beer 20.5 gallons 0 gallons
Substance abuse – social problem
48% people convicted of a crime used alcohol just before the crime
64% of offences violating public order are alcohol related
-Federal Correctional Institutions that offer D&A treatment 93.8%
-State Prisons that offer D&A
Efforts to reduce illicit drug use
Federal spending interdiction 1970s – 33% 1980s – 80%
Federal spending on treatment and education 1970s – 66% 1980s – 20%
War on drugs
Converging thoughts on reshaping drug policy in the U.S. by Conservatives and Liberals
Drug policy evolution
Federl law
Colorado
Washington
New Jersey
Pennsylvania – medical marijuana
- Adult use marijuana
Child welfare policy
Unfounded – investigated and found not to be anything
Founded – investigated and found to be true
Indicated – investigated and unsure of if it is happening or who is doing it
Nationwide child abuse 2012
9.2 victims per 1,000 children
Individual states wide variations
Low of 1.2 per 1,000 children
High of 19.6 per 1,000 children
History
1870s Children’s Aid Society – Charles Loring Brace
Boarding out
Efforts by charitable organizations to pay families to take children in
The family was going to get the benefit of this person contributing to their family
1874 – Edda Wheeler advocates for Mary Ellen
Edda Wheeler – church member, encounters Mary Ellen who is being boarded out at the church, discovers a lot of abuse
Pleaded to animal sympathizers, if we have standards for animals we must have standards for children
1875 – New York Society for Prevention of Cruelty to Children
By 1922 there are 57 by programs such as this
More so in urban areas
Orphan Trains West
Removal of children from New York, sent West and Mid-West to work on farms
They can have a better life if they get out of the city
Teddy Roosevelt comes into office – very progressive views
1909 – White House Conference
James West – Roosevelt has a meeting with him
James Addams – from settlement house, brings attention of child abuse to Roosevelt’s attention
1912 – U.S. Department of Commerce and Labor Children’s Bureau
1916 Child Labor Act – prohibit transport of child made goods to be sold between states
1921 Maternity and Infancy Act – programs to try to return maternal and infant mortality
1918 U.S. Supreme Court
Ruling overturned Children’s Bureau Act and Child Labor Act
1929 – President Hoover and Congress terminate Maternity and Infancy fund
Defunded
1925 – Social Security Act
Title IV (AFDC)
Title V (Maternal and Child Welfare Services – expanded)
1935 to 1996 AFDC – shared funding and administration
1996 PRWORA – shift
Less federal oversight
More focus on funding by federal government
“the era of big government is over”
1996 – of every 100 families in poverty 65 received TANF
2011 – of every 100 families in poverty 27 received TANF
Child services in U.S.
Fragmented state to state
Child Protective Services – 1960s x-rays
Dr. Kempe – Battered Child Syndrome
CAPTA Act of 1974 – model for all 50 states
Mid 1980s – reports UP…funding DOWN
2012 – abuse and neglect stabilize
Nationwide CHILD ABUSE 2012
9.2 victims per 1,000 children
Individual states wide variations
Low of 1.2 per 1,000 children
High of 19.6 per 1,000 children
Research
Annie E. Casey Foundation
State of the Child Report
PA Auditor General Eugene DePasquale
Family Preservation Model
1993 Promoting Safe and Stable Families
Child Protection
1997 Adoption and Safe Families Act (ASFA)
Termination of parental rights if child is in care for 15 of the last 22 months due to deaths of children in risky homes
Child Welfare Policy Driven by – fatal incidents
Questionable removals
Foster care
Placements
Number one reason is victim of child abuse
More than half the time the placements with CPS is child abuse
Number two reason is absence of the parents
For whatever reason they are unable to care for the child
AACWA (permanency planning)
Adoption Assistance and Child Welfare Act 1980
330,000 placements due to this act
By 1982 number was down to 252,000 foster care placements
Same sex foster parents
Foster Care Independent Living Act of 1999
Adoption
AACWA of 1980
Transcultural adoption
1978 Indian Child Welfare Act
Makes the tribe ultimately responsible for the removal and standards of the child
1980s NABSW position on transcultural adoption
They were against transcultural adoption
President Clinton
1996 non-interference in adoptions
Head Start
Economic Opportunity Act of 1964
Great Society Program
President Johnson
PRWORA 1996 – Head Start funding increased
Deficit Reduction Act 1990 – increased Head Start funding while reducing many other programs
Emerging issues
Day care
Federal Dependent Care Tax Credit
Title XX
Child Care and Development Block Grant
Maternal Child Health/Nurse – Family Partnership
Affordable Care Act
Yount Mothers/Teen Pregnancy
1980s new prohibition – War on Drugs
“It is the prohibition that makes anything precious” -Mark Twain
Number of drug seizures 1990 = 745,000
2000 = 2,800,000
“moral poverty”
Conservative viewpoint
Chronic poor different than transient poor
Touch Law & Order response needed
“Iron Triangle”
Investments/where’s the money going (in terms of government spending/tax dollars)
Efforts to reduce illicit drug use
1980s 1970s
Federal spending on interdiction
80% 33%
Federal spending on treatment and education
20% 66%
1980 to 2003 - criminal justice expenditures up 417.5%
Budget
PA DOC 2004-05 $1,300,000,000.00
2019-20 $2,600,000,000.00
New caste system “New Jim Crow”
Over representation of African American inmates
School to prison pipeline
Epstein vs lower socioeconomic class
Disproportionate justice
1991 Baltimore 56% African American males 18-35
1991 District of Columbia 42% African American males 18-35
1994 Crime Bill signed by President Clinton
Half of all African American males without high school diploma will be incarcerated at some point in life
Kids for Cash Luzerne County
Private detention center
Two judges
Profited off incarceration of minors
Kept the jail filled with minors that didn’t belong there
Private prisons & prison industrial complex
Government run institutions – looks to reduces populations and reduce costs
Private institutions – look to expand operations and increase populations to increase revenues (money spent on prisons)
Post great recession period
Incarceration vs probation/parole
Probation/parole is cheaper
Closing prisons
Medical marijuana
Legalization of drugs
Greater transparency
Housing
Conservative view
Supply and demand
Liberal view
Basic need
The American dream – owning your own home with a white picket fence
You should spend no more than 30% after tax income on housing
Average mortgage is $2,700
Current U.S. Housing Policy/Tax Structure
U.S. spends less on housing assistance than any other industrial nation
Tax deductions on mortgages of $1 million as well as $100K in home equity loans
80% of all tax benefits go to top 20% (>5% to bottom 60%)
Use of tax code – government incentives
Tax Abatement (exemption) Programs
KOZ – Keystone Opportunity Zones
Tax Incentive Programs
TIF – Tax Increment Financing (TIF) Guarantee Program
LERTA – Local Economic Revitalization Tax Assistance
Tax Reinvestment Programs
CRIZ – City Revitalization and Improvement Zone
Positive effects of home ownership
Stability, asset, community/environment awareness, health
Counties with the highest reverse-mortgage rates in 2010-16, Philadelphia had nearly 50 reverse mortgages per every 1,000 homeowners age 65 or older, the highest rate for 100 largest U.S. counties
Philadelphia 49.7
Salt Lake, Utah 44.9
San Diego, California 40.7
Los Angeles, California 40.6
Orange, California 40.3
Downside of ownership for low income families
Distressed neighborhood locations
Repair expenses for “fixer uppers”
Unstable employment in secondary job market
Subprime mortgages
Property taxes
House can be lost
Difficulty of finding affordable rentals
Housing bubble – foreclosures increased demand for rental units
Low after tax income (ELI – Extremely Low Income – 30% of area median income) (VLI – Very Low Income – 50% of the area median income)
Low income renters spend 13% to 44% of income on utilities (average is 4%)
Only 40% ELI renters received rental assistance
Revitalization
Gentrification
Landlords sell rentals
Rising property taxes
Relocation less than ideal
Housing discrimination is prevalent
Redlining
1988 – laws against prohibition of discrimination of renters with children
Homelessness
A simple, complex problem
Various causes, rooted in poverty
Mental health/drug and alcohol
Hidden/transient
Homeless children & unaccompanied youth
Reduced long term health status
Victims of abuse
Foster care
Older male teens separated from family
Individual adults
Veterans
Those over age 50
Long-term homeless linked to drug and alcohol issues
TANF
Domestic violence
Housing cost is the highest expense for long income families or individuals
McKinney Vento Act of 1987
Creates 20 different federal programs
1990 Amended
Modified by the HEARTH Act in 2009
Federal housing legislation (p. 335)
Housing Act of 1937
Housing Act of 1949
Housing Act of 1954
Model Cities Act of 1966
Housing and Community Development Act of 1974
Home Mortgage Disclosure Act of 1976
(CRA) Community Reinvestment Act of 1977
SNAP (Supplemental Nutrition Assistance Program)
1933 – food destroyed during depression
1939-1943 – surplus food, WWII, recovery
1964 – food stamp program 100% fed funding
50% / 50% state/federal administration
Farming
1960 – about 4 million farms in the U.S.
1998 – 2010 – 49k small farms are lost
49k large farms emerge (those earning $250k+)
45% of small family farms are “Hobby Farms” (owners work off site to bolster income)
Farmers are getting older and farms are getting larger
Corporate farms
CAFO
Waste
Genetic Enhanced Growth/antibiotics
Salmonella
Mad cow disease