final

Myth 2. Most poor people are on public assis- tance and the number is growing.

Fact. In 2015, only 1.3 million families were receiving TANF assistance on average in any given month.8 This represents only 14 percent of the 9.2 million families that levied below the poverty line in 2014. Clearly, many low-income families do not turn to TANF for support or are denied income support.

Myth 12. Welfare spending consumes a large por- tion of state budgets.

Fact. After adjusting for inflation, the amount states are required to spend (at the 80 percent level required by the federal government) in 2013 was about half of the amount they spent on AFDC-related programs in 1994. This sug- gests that the TANF spending burden is modest compared to other state expenditures.

Myth 11. Public assistance recipients migrate to states where benefits are high.

Fact. Although research by the Wisconsin's Insti- tute for Research on Poverty concluded that some poor people migrate across state lines to receive higher benefits,23 it failed to demon- strate that high benefits per se cause migration. According to Henry Freedman of the Center for Social Policy, "Census data on migration show that poor people move in the same direc- tion as those who are not poor, usually toward states with jobs and booming economies rather than those offering higher welfare benefits."24 Economist Bruce Meyer concluded that "The different methods all point toward the same result: there is welfare induced migration, but it is modest in magnitude.

Myth 10. It is easy to get on public assistance and too many undeserving people are receiving benefits.

Fact. David Morris noted that in the early 1990s, about 75 percent of those who walked into the welfare office to apply ended up on welfare rolls.21 Under TANF, states have broad discretion to determine eligibility and benefits. Nationally, TANF caseload have fallen by more than 60 percent since its inception in 1996, even as the numbers living in deep poverty have risen. Sixty-eight families received TANF for every 100 families in poverty in 1996; by 2013, only 26 fam- ilies obtained TANF for every 100 families in pov- erty.22 Some states drop entire families from the welfare rolls after the first instance of non-compli- ance (e.g., the refusal to accept an assigned job or identify a paternal parent) by the adult recipient.

Myth 7. Public assistance benefits provide a dis- incentive to work; people on welfare either do not want to work or are too lazy to work

Fact. In 2012, 17.6 percent of TANF recipients were employed part-time, 33.5 percent were unemployed, and 25 percent were not in the labor force

By 2000, both Democrats and Republicans had pronounced the PRWORA a raging success. The number of white families on welfare showed the steepest decline

First, caseloads had already begun to shrink—from a high of 5 million in 1994 to 4.5 million in 1996. These declines occurred before the PRWORA was fully implemented. Second, other factors, such as the strong labor market in the 1990s helped explain the drop. By the late 1990s, the nation was in the midst of the longest peacetime expansion in its history, with low unemployment and rising wages. Given that the PRWORA was conceived and passed by Congress in a strong economy with rising wages and low unemployment, its real test would occur in the global financial crisis that began in 2007.

Federal work requirements

For states tomeet federal work rules, 50 percent of fami- lies receiving TANF assistance must work for at least 30 hours a week (20 hours for single mothers with young children)

Important health care programs have served children, such as Medicaid and the State Child Health Insurance Program (SCHIP).

r

Many youth advocates objected to increas- ing the severity of punishment for adolescents, citing evidence that some violent juvenile crimes were abating.

r

The PRWORA replaced AFDC, JOBS, and the Emergency Assistance Program with the Tempo- rary Aid for Needy Families (TANF) program.

s

Americans who lack health insurance cost the economy billion a year in lost productivity.

t

Because a criminal record disqualifies virtually anyone from legitimate employment, incarceration automatically results in exclusion from the labor market, irregular family life, disqualification from voting, and eco- nomic marginalization.

t

Children under 18 in poverty were more likely to be uninsured

t

The direct inspiration for the British National Health Service was a 1944 white paper written by Sir William Beveridge, which argued that a "compre- hensive system of healthcare was essential to any scheme for improving living standards."

the aim was to pro- mote "the establishment of a comprehensive health service designed to secure improvement in the phys- ical and mental health of the people . . . and the pre- vention, diagnosis and treatment of illness.

n 1994, the Violent Crime Control and Law Enforcement Act introduced the "three strikes" penalties for repeat offenders and increased the number of federal crimes to which the death penalty applied.62 The number of prison- ers under the death sentence soared

the number of people of color with death sentences was thus more than double their proportion of the general population.

Americans steadily increased their consumption of alcohol from the end of World War II

v

Before 1965, medical care for those unable to afford it was primarily a responsibility of charita- ble institutions and state and local governments. In 1950, the federal government authorized states to use federal/state funds under the Social Security Act of 1935 to provide medical care for the indigent. In 1957, the Kerr-Mills Act provided for a federal /state matching program to provide health care for the elderly and the poor. However, Kerr-Mills was not mandatory, and many states chose not to participate

v

Even more alarming is the failure of the psy- chopharmacological industry to demonstrate the chemical process by which SSRIs actually worked, since biomedical research failed to show the causal effect. The "chemical imbalance" theory, a simplifi- cation holding that deficiencies of chemicals in the brain cause diagnosable disorders, is fundamental to antidepressants. Absent the causal process, the SSRIs enjoy the same status of aspirin, a remedy for symptom management. As behavioral pediatrician Lawrence Diller observes, "Aspirin fixes headaches, yet no one claims that headache sufferers have an 'aspirin deficiency.

v

The PRWORA also prohibits states from using federal TANF dollars to assist mostlegal immigrants until they have been in the United States for five or more years. States can, however, use MOE funds to provide benefits to recent immigrants, but less than half have taken that option. Neither federal nor state TANF funds can go toward undocumented immigrants.

v

The view of parental responsibility reflected in the PRWORA focuses on several themes

(1) fathers have a responsibility to financially support their children; (2) mothers have a responsibility to disclose paternity before receiving public assistance (a policy called establishment of paternity); (3) mothers who have physical custody of their chil- dren have a responsibility to financially provide for them through work efforts; (4) custodial parents are responsible for ensuring that their children receive educational opportunities; and (5) custodial parents are responsible for providing basic public health protection for their children, including immuniza- tions.

PRWORA goals. TANF and MOE funds must meet four primary goals of the PRWORA:

(1) the funds must be used for cash and other assistance to low-income families so that children are looked after in their own homes or in the homes of relatives; (2) promote self-sufficiency and end welfare dependency through job preparation, work, and marriage; (3) reduce the number of out-of-wedlock pregnancies through quantifiable goals; and (4) encourage the growth and maintenance of two-parent families.

There are three primary avenues for leav- ing TANF:

(1) voluntary termination because of employment, marriage, and so forth; (2) reach- ing the end of the federal or state time limit; and (3) being terminated for failure to comply with work or administrative rules. According to a U.S. Census report, 36.5 percent of former welfare recipients surveyed in 2009 cited that their reason for leaving TANF was due to their income becoming too high.

Despite federal guidelines, four important gaps exist in Medicaid coverage:

1) the low eligibility limits set for Medicaid, (2) the refusal of many states to adopt most or all of the Medicaid options, (3) the gaps in coverage for the elderly and disabled, (4) the ineligibility of some poor single persons and childless couples if they are not elderly or disabled, and (5) state cutbacks in Medicaid coverage.

Another issue underlying the welfare reforms involves (re)marriage.

According to several stud- ies, many—if not most—mothers voluntarily leave public assistance due to a change in marital status. Yet public assistance programs punish marriage in two ways: (1) how they treat a mar- ried couple with children and (2) by how they treat families with stepparents. First, a needy two-parent family with children is less likely to be eligible for aid than a one-parent family. Although the non-incapacitated two-parent family can apply for TANF, many states require work expectation and time limits that make the program inaccessible to many poor families. Second, a stepparent has no legal obligation to support the children of his or her spouse in most states. Nevertheless, TANF cuts or limits benefits when a woman remarries by counting much of the stepparent's income when calculating the family's countable income, thus jeopardizing the mother's eligibility status.

in search of alternatives to incarceration, states began piloting evidence-based interventions. For example, Functional Family Therapy (FFT) returns $10.46 for every dollar invested and produces better outcomes. FFT provides juveniles and their families up to 30 hours of intervention over a three-month span, in three phases: engagement and motivation, behavior change, and generalization. The objective of FFT has been to encourage delinquent youth and families to identify strengths, mobilize resources, and build constructive networks. The cost of FFT is about $3,750 per youth.

African American youth incarcerated for drug offenses are good candidates for evidence-based interventions, such as FFT.

Name the key public assistance programs

Aid to Families with Dependent Children (AFDC); AFDC's replace- ment, Temporary Assistance to Needy Families (TANF); Supplemental Security Income (SSI); and general assistance (GA)

The ACA required most U.S. citizens and legal residents to have health insurance.

Almost everyone by 2014—with the exception of some low-income people—must have purchased health insurance or face a $695 annual fine.

note

Although expenditures for public assistance programs are far less than for social insurance programs, they tend to be more controversial

Explaining the High Cost of U.S. Health Care

Although malpractice insurance costs are dropping for some medical specializations,the costs are still high. The fear of med- ical malpractice suits results in some doctors practicing "defensive medicine" by ordering largely unnecessary tests for patients to avoid a possible lawsuit. The United States leads the world in the development and use of medical technology, but these advances have come at a high price. Expensive new pharmaceutical drugs drive up costs considerably. The higher prevalence and treatment of chronic diseases, such as diabetes, has also driven up health care. Longer lifes- pans for a chronically ill patient means more care and treatment, which helps to drive up medical costs. The administrative costs involved in process- ing millions of insurance claims add to rising health care expenditures. (1) $210 billion in unneeded ser- vices, (2) $75 billion in fraud, (3) $190 billion in excessive administrative costs, (4) $130 billion in inefficient services, (5) $105 billion in excessive prices, and (6) $55 billion wasted through missed prevention opportunities.

Economic Opportunity Act of 1964

An economic legislation that created many social programs to help provide funds for youth programs antipoverty measures, small-business loans, and job training; part of the Great Society.

permanency planning

An effort by child-welfare authorities to find a long-term living situation that will provide stability and support for a maltreated child. A goal is to avoid repeated changes of caregiver or school, which can be particularly harmful to the child.

Child protective services, foster care, adoption, and Head Start have been the focus of child welfare policy since the 1960s.

Because the United States has failed to establish a family policy that ensures basic income, employment, and social service supports to parents, parents frequently have dif- ficulty in caring for their children

Substandard care also exposes child welfare professionals to liability. The qualified immunity of child welfare workers established through DeShaney v. Winnebago County Department of Social Services (1989) was successfully challenged in Currier v. Doran (2001) in which child wel- fare workers were found liable when their actions "created the danger" that harmed a child.

Cur- rier has momentous implications for child wel- fare professionals. Foremost, "social workers who blatantly fail to heed warning signs of abuse or potential abuse will not be protected from liabil- ity."46 But Currier has much broader implications. Workers cannot claim that high caseloads due to agency underfunding provide an excuse for neg- ligence. Moreover, supervisors are legally liable if their "deliberate indifference" to clients' welfare is reflected in their failure to adequately train subor- dinates.47 Thus, Currier underscores the need for child welfare professionals to demand adequate resources in order to meet their obligations to pro- vide adequate care for at-risk children.

The information provided by NCHS helps to:

Document the health status of the population and of important subgroups Identify disparities in health status and use of health care by race/ethnicity, socioeconomic status, region, and other population characteristics Describe various experiences with the health care system Monitor trends in health status and health care delivery Identify health problems Support biomedical and health services research Provide information for making changes in pub- lic policies and programs

Myth 1. Many families on public assistance include an able-bodied father who refuses to work.

Fact. In 2015, only about 66,000 of the monthly average of 1.3 million TANF families (1/2 percent) were two-parent families.4 This was a significant drop from the 342,000 two-parent TANF families in 1995.5 The majority of TANF families are headed by mothers who are unmar- ried, divorced, widowed, or separated.6 About 90 percent of TANF children live with their mothers and 10 percent with their fathers.

Myth 9. Never-married teen mothers constitute the bulk of welfare recipients.

Fact. In 2015, teen parents made up less than 5 percent of the TANF caseload. Of the overall TANF caseload, only 5 percent of adult ben- eficiaries were under age 20

Myth 6. Most welfare recipients are African Americans and Hispanic Americans.

Fact. In 2015, whites constituted 61 percent of recipients, while 33 percent were black, and 9 percent Hispanic. Although the percentages of Afri- can Americans and Hispanics on the welfare rolls were larger than these groups' represen- tation in the population, this is not surprising, since people of color are statistically poorer than whites.

Myth 3. Recipient mothers have more children in order to collect greater benefits; therefore, fam- ilies on public assistance are large and steadily growing in size.

Fact. The average size of families receiving TANF benefits in 2013 consisted of one child. In 2015, at least five states (California, Washington, South Carolina, Wisconsin, and New Mexico) had cut monthly cash assistance that prohibited TANF families from receiving additional assistance for any child born after the mother has enrolled in the program.

Myth 14. TANF families are largely made up of a mother who refuses to work.

Fact. The bulk of TANF recipients are children. Out of 4 million TANF recipients in 2005 almost 3 million were children. The TANF caseload is varied and diverse. The stereotyp- ical TANF family with one unemployed adult constituted only 45 percent of all beneficiary families in 2013. Moreover, 17 percent of fam- ilies receiving TANF had an employed adult, while 38 percent were "child-only" (there was no adult recipient). This category included fam- ilies with a disabled adult receiving Supplemen- tal Security Income (SSI), non-parent adults (e.g., grandparents, aunts), and families with an ineligible noncitizen parent.

Myth 8. Public assistance recipients are doing better than ever.

Fact. The reverse is true. Four states had lower TANF benefit levels in 2010 than in 1996; 16 states had the same benefit levels as in 1996. Even those states that raised TANF benefits have generally not kept pace with inflation. When adjusted for inflation, 48 states have lower real-dollar benefit levels in 2010 than in 1996.18 Today, the maximum benefit amount in 30 states comprises 30 percent or less of the federal poverty level.

Myth 4. Once on welfare, always on welfare.

Fact. This has become a moot point, since the 1996 TANF regulations instituted a five-year lifetime benefit cap for recipients.12 The num- ber of welfare recipients who return after a period of employment is relatively modest

Myth 13. TANF benefits influence decisions relat- ing to family composition (i.e., childbearing, marriage, divorce, and living arrangements) by encouraging women to head their own households.

Fact. Under the TANF guidelines, teenage moth- ers under age 18 are not entitled to benefits unless they are living at home or in a super- vised facility. Although some empirical stud- ies found a small correlation between public assistance benefits and the number of women who choose to head households or remarry, most researchers believe that the evidence does not support the view that generous benefits are responsible for high illegitimacy rates or the growth of single female-headed households. For example, although total welfare benefits have declined since 1975, the number of single female-headed households has remained rela- tively constant.27

Myth 5. Welfare programs create intergenera- tional dependency.

Fact. Welfare dependency theories are predicated on the belief that welfare weakens traditional values around nuclear families, individual- ism, initiative, and self-determination. Given the lifetime cap on TANF cash assistance, the dependency issue has become less relevant. Even before TANF, the vast majority of AFDC recipients were on public assistance for less than four years;

HI or Part A is provided free to persons age 65 or over who are eligible for Social Security or Railroad Retirement benefits.

HI is a compulsory inpatient care (hospital) insurance plan (it also includes some nursing and home health care) with premiums derived from a payroll tax that is part of the Social Security deduction.

Managed care became a household word in the 1990s. By 2014, almost 86 million Americans were enrolled in HMOs

Health Maintenance Organizations (HMO)— a prepaid or capitated insurance plan in which individuals or their employers pay a fixed monthly fee for services rather than a separate charge for each visit or service.

Medicare payments for most inpatient hospital services are made under a reimbursement mechanism known as the prospec- tive payment system (PPS). Under PPS, a predeter- mined amount is paid for each inpatient hospital stay based on a diagnosis-related group classifi- cation. In some cases, the payment to the hospital is less than the actual costs, while in other cases it is more. The hospital absorbs the loss or makes a profit.

If a doctor or medical supplier agrees to accept the Medicare-approved rate as payment in full (which they often refuse to do), they may not request any additional payments from the benefi- ciary

the absence of sound labor policy rewards low-wage employers while punishing low-income workers forced into poorly paid dead-end jobs that provide little, if any, bene- fits. Specifically, low-wage employers are rewarded by not being required to provide employees with a minimum number of hours, benefits, or employ- ment perks. These employers are subsidized by not having to pay the requisite salary to support a worker and his or her family

In effect, low-wage employers are subsidized by taxpayers through the Earned Income Tax Credit (EITC), child tax credit, food stamps, and Medicaid, which partially makes up the shortfall between low salaries and the real cost of living. Moreover, compelling former recip- ients to become engaged in the workforce using a lifetime benefit cap did not ensure permanent labor force attachment (as seen during the 2007 to 2008 recession), especially in a weak economy.

By the 1980s, events had propelled the control of drug abuse to a top priority in U.S. criminal justice. The deterioration of inner cities had been accompa- nied by an alarming degree of social dysfunction. Illegal drugs were not only prevalent in the poor- est minority neighborhoods but had also become an essential, if not the predominant, part of the local economy. As gangs vied over turf and ever more profitable drug peddling, violence exploded.

In response, former President Reagan declared a war on drugs.

note

Many states have developed policies that attempt to divert assistance from applicants needing the least amount of state help to encourage them to become self-sufficient. As of October 2015, 48 states had created for- mal "diversion programs" that included job search requirements for eligibility or provided a one-off, lump-sum payment to deal with imme- diate needs instead of providing applicants with a monthly TANF benefit.9 Families that accept diversion payments are typically barred from applying for monthly TANF benefits for a stated period of time.

Another potential solution involves building "smart guns" using biometrics. By using fingerprint or radio frequency technologies, smart guns would be operable only by the owner.

Not surprisingly, the NRA is opposed to mandatory "smart gun" requirements based on the fear that it is a step toward gun control.

The most notable involves prohibiting the use of TANF funds to assist families where an adult has received assistance for 60 months or more.

Other restrictions include a prohibition on assisting minor parents unless they are attending school and living at home or in an adult-supervised living arrangement (subject to limited exceptions), and a requirement to reduce or eliminate assistance if an individual does not cooperate with child support-related requirements, such as identifying the father.

Medical services in the United States consist of five major components:

Physicians in solo practice. Group practice settings, including physicians that share facilities. Physicians employed in corporate-owned for- profit clinics or in nonprofit clinics. Hospitals—private, nonprofit, or public. Public health services delivered on the state, local, regional, national, or international level. These services include health counseling, family planning, prenatal and postnatal care, school health services, disease prevention and control, immunization, referral agencies, STD (sexually transmitted diseases) services, environmental sanitation, health education, and maintenance of indexes on births, deaths, and communicable diseases. Corollary health services, which includes home health services, physical rehabilitation, group homes, nursing homes, and so forth.

Critics charge that the MMA may actually increase drug costs by prohibiting Medicare from using its potentially huge purchasing power to negotiate lower drug prices

The "no negotiation" clause increases program costs, which in turn, adds to the overall costs of Part D

The NHS is currently the world's largest pub- licly funded health service

The backbone of the NHS is the GP, and every patient in Britain is registered with one. GPs are paid by the NHS on the basis of an annual capi- tation (per-person) fee for each registered patient.

SSI is a public assistance program funded by general revenue taxes, while Social Security is a social insurance program funded largely by contributions.

The SSI program began during the Nixon presidency as a substitute for a number of state- operated disability programs

note

The U.S. social welfare state is a complex mix- ture of programs, policies, and services. Perhaps few people, including many policymakers, fully appreciate the complexity of the welfare system. One reason is that unlike many European countries that operate under a comprehensive and integrated welfare plan, the United States relies on a patch- work quilt of social welfare programs and policies. Hence, public assistance in the United States is a disorganized mix of programs and policies, rather than a comprehensive, integrated, and non-redun- dant system of social welfare services.

Protective services for children began with one of the more unusual incidents in U.S. social welfare. In 1874, a New York church worker, Etta Wheeler, discovered that an indentured nine- year-old child, Mary Ellen, was being tied to a bed, whipped, and stabbed with scissors. On investigating what could be done for Mary Ellen, Wheeler spoke with the director of the New York Society for the Prevention of Cruelty to Animals (NYSPCA) on behalf of the child. Although it was subsequently misreported that intervention on behalf of Mary Ellen was predicated on her status as an animal, rather than as a child, a care- ful review of the case indicated that Mary Ellen's case was adjudicated consistently with legal prec- edents involving abused children.

The following year, the New York Society for the Prevention of Cruelty to Children was established.

The welfare behaviorism inherent in the PRWORA reflects a belief in the importance of personal and parental responsibility

This philosophy harks back to supposedly traditional "main street" values of self-reliance, independence, and individual respon- sibility. It also includes a de facto belief in the lim- ited role of government.

The Social Security Act of 1935 addressed child welfare through two provisions. Title IV introduced the Aid to Dependent Children program, which provided public relief to needy children through cash grants to their families.

Title V reestablished Maternal and Child Welfare Services and expanded the mandate of the Children's Bureau to oversee a new set of child welfare services "for the protection and care of homeless, dependent, and neglected children, and children in danger of becoming delinquent."

A decade of war in Iraq and Afghanistan resulted in serious mental health problems among many of the 2.5 million service members returning from deploy- ments in Iraq and Afghanistan.

Unlike the Vietnam conflict, the prevalence of Traumatic Brain Injury (TBI) and Post-Traumatic Stress Disorder (PTSD) was signifi- cantly higher.6

. In countries like France, Denmark, Sweden, and Germany, family benefits are univer- sal, while in others like the United States, Canada, Czech Republic, and Italy, they are means-tested (e.g., the EITC and Child Tax Credit)

a

Originally called Aid to Dependent Children (ADC), the AFDC program was part of the Social Security Act of 1935 and was designed to provide support for children by dispensing aid to their mothers.

a

Promoted early by the Reagan administration, this ideological perspective has been labeled the "devolution revolution" or the "new federalism." Energized by the cry of "states' rights," the new federalism traded off long-term stable federal funding for increased state control through block grants.

a

Replaced by TANF, AFDC was arguably the most controversial program in the U.S. welfare system. AFDC was designed to provide financial assistance and care to needy dependent children in their own homes or in the homes of responsible caregivers.

a

States must deny cash assistance and Food Stamp Program benefits to recipients convicted of felony drug possession, use, or distribution.

a

Head Start Program

a federal program that provides academically focused preschool to students of low socioeconomic status

preferred Provider Organizations (PPO

a type of hMo whereby an employer or insurance company contracts with a selected group of health care delivery providers for services at pre-established reimbursement rates. Consumers have the choice of who to contact to provide the service. if a doctor is not on the provider list, higher out-of-pocket expenses will result.

General assistance (GA) programs

also known as General Relief programs in some states, are cash and in-kind assistance programs financed and administered entirely by the state, county, or local- ity in which they are located. These programs of last resort are designed to meet the short-term or ongoing needs of the severely poor without chil- dren, who are ineligible for (or awaiting approval for) mainstream federally funded programs, such as TANF or SSI. In many ways, GA programs serve some of the poorest of the poor.

Even if an anti-gun law were passed, eliminating the 310 million guns in the United States would be impossible. One way to lower the number of guns in circulation is through a gun buyback program.

g

Among the most pernicious effects of alco- hol consumption is fetal alcohol syndrome (FAS), a physiological and mental deformation in infants caused by their mothers' ingestion of alcohol during pregnancy

b

Because of the economic circumstances of poor families, child labor emerged as a primary concern of early child welfare advocates. The absence of public relief meant that families were compelled to work at whatever employment might be available. Children worked full shifts in coal mines and tex- tile mills; women labored in sweatshops. Neither group was protected from dangerous or unhygienic working conditions

b

Despite these conservative arguments, the absence of sound federal labor policy, the historic lack of guaranteed health care insurance, and few workplace protections resulted in most former recipients going from the frying pan into the fire. Many former recipients ended up in secondary labor market jobs where they faced an even more uncertain economic future than under AFDC.

b

Forced confessions, admissions of guilt under duress, have been disputed by DNA evidence in 24 percent of 289 sentences reviewed by the Innocence Project.73 The entire system is so flawed that Supreme Court Justice John Paul Stevens wrote: "criminal statutes have limited the discretionary power of judges and juries to reach just decisions in individual cases, while the proliferation and breadth of criminal stat- utes have given prosecutors and the police so much enforcement discretion that they effectively define the law of the street."

b

In all but two states, the inflation-adjusted value of TANF cash benefits has fallen since the PRWORA came into effect. In today's dollars, TANF cash benefits are worth 20 percent less than in 1996.

b

Increasing demand for foster parents and homosexual rights collided in a controversy about the suitability of gays and lesbians as parents. A Texas child welfare supervisor ordered the removal of a foster child from a lesbian foster parent, argu- ing that the state's anti-sodomy statutes defined homosexual households as unacceptable.56 An Arkansas judge ruled a state ban on placing fos- ter children with families having a gay member as unconstitutiona

b

Jerome Miller contended that "crime" was largely an attempt to control minority youth, which was challenged by conservative crime theorists. Conser- vatives argued that the chronic poor suffered from problems qualitatively different from those of the temporarily poor.

b

Perhaps the most important part of the MMA is a little-noticed component called health savings accounts (HSAs), which offers a tax-free shelter for those with high-deductible insurance. When money is put into an HSA, it is not taxed. Nor is it taxed when the money is removed to pay for medical costs.

b

Rather than admit the extent of problems in children's services, workers used confidentiality as an excuse to avoid public accountability.

b

Responding to concerns about intergenera- tional welfare dependency, states began implement- ing "diversion" programs to keep families whose needs could be met through other means from ever entering the welfare rolls. In response to higher effective work participation rates that followed the reauthorization of the TANF program in 2005, states added new policies and programs that divert TANF-eligible families from the TANF system. Three kinds of diversion strategies are employed: (1) lump-sum payment programs provide appli- cants who are employed or have a job offer with the option of accepting a one-time cash or voucher payment, in lieu of receiving TANF; (2) appli- cant work requirements target applicants likely to be subject to the TANF work requirements and require them to participate in work-related activi- ties during the 30- to 45-day application certifica- tion period; and (3) temporary support programs provide TANF applicants with up to four months of assistance, which do not count toward TANF time limits or work participation rates. All but three states have implemented at least one diver- sion strategy, with 35 states adopting a lump-sum payment program.

b

Simon to identify the advent of a "new penology." In contrast to the old penology that focused on individual rehabilitation (via probation or parole) or deterrence (via incarceration), the new penol- ogy eschewed these for the efficient management of large populations of high-risk offenders. The mis- sion of criminal justice, they contended, was "man- agerial, not transformative"65; the social function of criminal justice was "rabble management,"66 or controlling "unruly groups.

b

Static funding has prompted innovation in service delivery. An example of how a capitation method of payment could be used in mental health service delivery was the integrated mental health (IMH) concept pioneered in New York State and Philadelphia. Capitated mental health care under IMH would have three major features: First, current categorical grants—Medicaid, Supplemen- tal Security Income, Food Stamp Program, local funding—would be aggregated into a common fund from which capitation "premiums" would be paid. Second, a nonprofit planning and coordina- tion agency would be established to oversee men- tal health care and in so doing negotiate contracts with providers, monitor performance, and evolve innovative programs. Third, particularly high- usage clients would be targeted for provision of less costly services in order to generate surpluses for less-intensive services.5

b

TANF block grants to states has been frozen at $16.5 billion since 1996.

b

TANF provides lump-sum federal block grants for states to operate their own welfare and work programs. States must also spend their own money on programs for poor fam- ilies lest they face high financial penalties. This requirement, known as "maintenanceof effort" (MOE), mandates that for states to receive their full block grant, they must spend their own funds at 80 percent of their historic spending level based on 1994 spending.

b

The act provides financial incentives to states to reduce their out-of-wedlock birth rates, while at the same time lowering their abortion rates. In addition, child support collection efforts were strength- ened through a number of provisions.40 The PRWORA allows states to impose a family cap that denies assistance to children born into families already receiving public assistance.

b

The requirement for receiving AFDC was that a child be deprived of the parental support of one parent because of death, desertion, separation, or divorce. (In the case of the AFDC-Unemployed Parent program, the criterion was deprivation of parental economic support because of unemploy- ment or illness.)

b

The toll of incarceration on adolescent devel- opment would be steep, as evident in the deplorable conditions of institutions serving minority youth.

b

Under the PRWORA, federal entitlement to public assistance was ended. In contrast, the former AFDC program operated under the principle of entitlement, which meant that states must provide assistance to anyone eli- gible under the law. This did not mean that states were required to provide something for nothing. In fact, states could have required recipients to par- ticipate in work, education, training, or job search programs as a condition for receiving aid. Under TANF, no family or child is entitled to assistance.35 In effect, the TANF disentitlement rescinded the 60-year-old federal entitlement for support to poor children and families.

b

large cities had children's aid societies that prac- ticed "boarding out" of children (the payment of a fee for child rearing) to sponsors in the commu- nity.5 The boarding out of children until adoption (except in the case of children with disabilities, who were unlikely to be adopted) was the forerunner of today's foster care and adoption programs in the United States.

b

All this would be an exercise in psychophar- macological frivolity, except for the quite real side effects attributed to SSRIs. "Symptoms of serotonin syndrome include restlessness, hallucinations, loss of coordination, a racing heart, rapid changes in blood pressure, fever, nausea, vomiting, and diar- rhea," noted Kirsch, "SSRIs can provoke an agi- tated restless state called akathisia, which some people describe as feeling like jumping out of their skin. It is often in this state that people on SSRIs become violent and aggressive toward themselves and others.

c

As a result of a foundering desinstitutionaliza- tion movement, mental health advocates became more assertive

c

As noted in the Criminal Justice chapter, police are often called to deal with deviance associated with mental disorders. Since 2011, Albuquerque police have killed several mentally ill citizens

c

As state hospitals converted from long-term cus- todial care to short-term patient stabilization, psychotropic medication became a routine form of treatment

c

As states discharged patients from state institutions, they realized immediate savings. By the end of the 1990s, 93 percent of the state psy- chiatric beds that had existed in 1955 were lost to deinstitutionalization.

c

In Wyatt v. Stickney, Ala- bama District Court judge Frank Johnson ruled that the state of Alabama was obliged to provide treatment to patients in state hospitals, a judgment with which the state subsequently failed to comply. Shortly thereafter, in Donaldson v. O'Connor, the Supreme Court determined that "the state could not continue to confine a mentally ill person who was not dangerous to himself or others, who was not being treated, and who could survive outside the hospital." Finally, in Halderman v. Pennhurst, the Third District Court established that institu- tionalized patients deserved treatment in the "least restrictive alternative."

c

One early teen pregnancy prevention program was Project Redirection. From 1980 to 1982, 805 AFDC-eligible mothers aged 17 or younger received intensive services to optimize educational, employment, and life management skills. The out- come was disappointing. Project Redirection teens fared no better than the control group in obtain- ing a high school diploma or GED certificat

c

Only persons dangerous to them- selves or others could be hospitalized involuntarily. For those hospitalized, involuntarily or otherwise, states were obliged to provide adequate treat- ment in the manner that was least restrictive to the patient.

c

The self-serving circle between psychiatry and the psychopharmacological industry was closed in more pedestrian ways: Fifty percent of the drafters of the DSM V reported significant income from drug companies

c

a strong correlation exists between young single motherhood and welfare dependency. Teen mothers who grew up on public assistance were more than twice as likely to be dependent on welfare themselves.

c

In 2000, NMHA changed its name to Mental Health America (MHA), but was soon engulfed in a controversy when it was revealed that donations from pharmaceutical companies were made in exchange for support for psychoactive medications to treat mental disor- ders. The politicization of mental health care thus compromised the best interests of care for those suffering from mental disorders.

d

Child and family welfare initiatives remained unsuccess- ful until the Social Security Act of 1935 ushered in an array of welfare policies.

j

With the Omnibus Budget and Reconciliation Act of 1981, however, the Reagan administration collapsed all mental health funding into a block grant available to states for any mental health services they deemed fundable.

d

"We took them away from their parents on the assump- tion that we as a society would do a better job of raising them," observed researcher Mark Court- ney, "We've invested a lot of money and time in their care, and by many measures they're still doing very poorly."62 In 1999, the Foster Care Indepen- dent Living Act provided funding for education and employment services for children who were aging out of foster care; foster youth were entitled to vouchers worth up to $5,000 per year for higher education, for example.

g

Begun early in the twentieth century, the National Mental Health Association (NMHA) pioneered efforts to provide social support and treatment for the mentally ill

during the Progressive Era, the eugenics movement contributed to the institutional abuses that were condemned by NMHA. Propo- nents of eugenics argued that mentally impaired patients often suffered from hereditary deficiencies that should be prevented by sterilization. Adher- ents of eugenics were less concerned about the civil rights of individual mental patients than they were about the future of civilization—the fact that some patients might object was merely an inconvenience.

The Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services oversees the fed- eral alcohol, drug abuse, and mental health block grants.

e

Aging state prisons as well as need for federal immigration facilities are reasons for expansion of the for-profit correction industry.

f

Although far from ideal, mental health ser- vices to veterans have been at least coordinated by national organizations that could be held account- able, unlike care for civilians, which remained frag- mented under state authority.

f

Not only did the DSM become the bible of psychiatry, but like the real Bible, it depended a lot on something akin to revelation,"

f

the Indian Child Welfare Act of 1978. Native Americans were disturbed that "25 to 35 percent of all American Indian children [were] separated from their families and placed in foster homes, adoptive homes, or institutions."74 The fact that 85 percent of such placements were in non-Indian families and left the children "without access to their tribal homes and relationships" raised the specter of par- tial cultural genocide.75 To reinforce the cultural identity of Native American children, the Indian Child Welfare Act provided for "minimal Federal standards for the removal of Indian children from their families and the placement of such children in foster or adoptive homes which will reflect the unique values of Indian culture, and for assistance to Indian tribes in the operation of child and family service programs."76 Equally important, the Indian Child Welfare Act established tribes, rather than state courts, as the governing bodies responsible for Indian foster children. The 2008 Fostering Con- nections Act provided Native American tribes with direct access to federal child welfare funding.

f

Finally, because of his experience with mental retardation as a family problem, a sister who was seriously impaired after a lobotomy, former president John F. Kennedy was supportive of programs that promised to improve mental health care.

fe

in Western cultures, irrational conduct is usually understood as a men- tal health disorder, whereas deviant behavior on the part of a rational actor falls under the purview of law enforcement.

fg

Household and private business spending has declined since 1987, and spending by government has increased from 32 percent in 1987 to around 44 percent. This is largely due to Medicare, Med- icaid, and CHIP, which comprise more than one- third of total national health care expenditure

g

The last decades of the twentieth century wit- nessed a boom in prison construction, a devel- opment that drew the wrath of opponents of incarceration. Prison is an expensive way to man- age deviants, costing $22,000 on average per inmate annually.10 Since states pay most of the costs for incarceration, prisons vie with schools for funding, a competition that is decidedly skewed.

g

The process by which so many minority youths become inducted into the criminal justice system has been described as the "school to prison pipeline," suggesting that exclusionary experiences in school are followed by immersion in the juvenile justice system, a precursor to adult corrections. Accord- ing to the Department of Education's Office of Civil Rights, black males are twice as likely as white males to be arrested after altercations at school

g

The rising costs of Medicare have led the federal government to seek alternative ways to lower hospital costs, including the Prospective Payment System (PPS). In this system, the federal government specifies in advance what it will pay for the treatment of 468 classified illnesses or Diagnostic Related Groups (DRGs).

g

classes who are protected by good health insurance. Although most Americans are covered by private insurance plans, gaps in private health insurance may include high deductibles and copayments, limits on hospital stays, dollar limits on payments to hospitals and physicians, exclusion of certain laboratory tests, and so forth. Because privately purchased health insurance have become almost unaffordable, the availability of health insur- ance may be a major factor in an individual's job search or decision to continue in a job.1

g

Two strategies dominated the War on Drugs:

government interdiction of supplies, aimed at eliminating the substance, and treatment programs deployed to diminish the demand for illegal drugs.

Although a desirable outcome for children in foster care would be reunification with biological parents better able to care for them, about 25,000 foster children simply age out of care each year.

h

By 2012, the Innocence Project marked the release of 300 wrongfully convicted inmates. Of those released, 187 were African Americans, and their average length of incarceration was 13.6 years; yet, only 60 percent have been compensated for their wrong- ful convictions.75 Civil rights loomed large in the Innocence Project because a disproportionate number of inmates scheduled for execution were minorities of color.

h

From the standpoint of permanency planning, adoption has become an important child welfare service. In the early 1980s, the Children's Bureau noted that 50,000 "hard-to-adopt" children were waiting for homes. Many of these children were of minority origin, had disabilities, or were older and had been in foster care for several years; yet, sub- sidized adoption proved cost-effective, 37 percent less than foster care.70 Because such children posed a financial burden for adoptive parents, AACWA provided subsidies to adoptive parents.

h

Given this double burden, it is understand- able how delinquency-prone youth could find gang involvement a natural progression in socialization.

h

In 2008, President George W. Bush signed Fos- tering Connections to Success and Increasing Adop- tions Act, the most extensive child welfare reform in three decades. Among its provisions were guard- ianship payments to relatives of children in foster care, tribal access to federal child welfare funding, and an extension of benefits to foster children until age 21 providing they are in school or working.

h

In the 1960s, reports of child maltreatment increased as a result of advances in radiological technology. A pediatrician, C. Henry Kempe, iden- tified non-accidental injuries to children as the battered child syndrome.

h

Momentum toward legalizing drugs provoked a volatile debate. Although proponents of drug legalization argued that people dependent on mar- ijuana, heroin, and many psychedelics could use their drugs discreetly without disrupting society, opponents contended that the proliferation of crack cocaine and crystal meth presented a completely different picture. Not only were crack and meth implicated in violent incidents, but the craving for them was also more intense than that for many other drugs. Methamphetamine in rural states was implicated in a significant increase in the number of children placed in foster care.85 The prospect of legalizing a substance over which users seemed to have so little control, and which, moreover, was connected to homicides, addicted infants, and fam- ily destruction, seemed inconsistent with the vision implied by drug legalization.

h

Police misconduct has been addressed through several strategies. Police civilian review boards have been established in several cities, although police tend to oppose such oversight. Improved training of police with regard to non-lethal apprehension of suspects, especially the inebriated and mentally ill has also been undertaken. More recently, video cameras have been added to police cars as well as officers' vests in order to record interactions with suspects. While technology can be helpful in recording police-citizen interactions, it is inherently limited. Police can engage in unlawful conduct out- side the view of the camera or they can simply turn the camera off

h

The Children's Bureau Act of 1912 established a national agency to collect information on children. The Child Labor Act of 1916 prohibited the inter- state transportation of goods manufactured by children. The Maternity and Infancy Act of 1921 assisted states in establishing programs that dramatically reduced the nation's infant and maternal mortality rates.

h

The low ranking of the United States can be attributed to two factors: the high incidence of poverty among American children and the absence of universal health care for their families

h

The passage of the "three strikes" legisla- tion targeting repeat offenders, the War on Drugs, and the consequences of the sentencing guidelines provided the prison-industrial complex with a more-than-adequate supply of inmates. Because most inmates were nonviolent offenders, incarcera- tion in the minimum- and medium-security facilities that were favored by for-profit firms proved ideal.

h

The traditional expectation was that an armed person must first try to retreat to escape the danger. Only if there is no escape is the use of lethal force permitted. However, the "stand-your-ground" law removes the duty to retreat before using force in self-defense. The law permits an armed person to not retreat and use lethal force in any location they are legally allowed to be. This was the basis of the acquittal of George Zimmerman in the Trayvon Martin case in Florida.

h

Ultimately, the public pays for police violence not only through individual injury but also by higher taxes assessed to the public to reimburse victims.

h

one of the most dramatic gaps is the frequent failure of some private health insurance plans to cover catastrophic medical costs—those costs that could reduce a middle-class family to "medically indigent" status within only a few months.

h

Annually, 3.2 million children are investigated for abuse and neglect,42 how- ever, a large portion of reports are unsubstantiated, associated with anonymity in reporting.43 Mischief in reports of maltreatment, attributable to unhappy children and vengeful ex-partners, divert child wel- fare resources from interventions involving founded cases of maltreatment.

j

Because minorities of color have been dispropor- tionately incarcerated, race and ethnicity have been fundamental to understanding criminal justice. After the Civil War, the passage of "Jim Crow" laws intended to deny African Americans their civil rights, institutionalized racism in public policy for a century and, in the process, subjugated Blacks.

j

In September 2011, a four-year- old girl weighing 18 pounds died, despite the pro- vision of children's services.23 In an unprecedented response, the Brooklyn district attorney indicted a child welfare worker and his supervisor for crim- inally negligent homicide for failing to protect the child.24 Efforts to make child protection more accountable by state statute requiring openness of cases involving child fatalities, foundered on the shoals of the child welfare bureaucracy: An inves- tigation by the New York Times revealed that the state's Office of Child and Family Services had been working to keep cases involving child fatalities secret.25

j

The get-tough mindset that typified correc- tions during the 1990s was shaken when increas- ing numbers of inmates were exonerated from crimes for which they had been convicted.

j

The need for child day care is felt both by middle-income fami- lies, in which both parents work in order to meet the income requirements of a middle-class lifestyle, and by low-income families, in which a parent is encouraged or required to participate in a welfare- to-work program. Yet, the child care available is often unreliable, expensive, and of questionable quality.

j

By incarcerating large numbers of citizens, the United States not only incurs the costs of imprison- ment but also further disadvantages minority com- munities that represent a large portion of inmates.

k

Deviance is also an issue of social justice because poor people and minorities of color are disproportionately repre- sented among those incarcerated in mental as well as correctional institutions.

k

Financially distressed state and local governments reconsidered their commitments to incarceration, primarily because of the costs involved. The Pew Charitable Foundation calculated that a day in prison cost $79 compared to $3.50 per day for probation or parole

k

Notably, most developed nations have incarceration rates that are a fraction of that of the United States.

l

The rapid deterioration of child welfare services led children's advocates to call for more funding of social services

l

crimes have been classified according to personal injury or property damage. Recently, the designation of hate crimes can add to punishment adjudicated for crimes against per- sons and property. Hate crimes are classified in five groups, those motivated by race, religion, sex- ual orientation, ethnicity, and disability

l

A study of Georgia facilities commissioned by the Justice Department concluded that boot camps failed to deter young offenders.22 In 1994, Connecticut closed its National Guard boot camp, citing "rampant gang activity, assaults on weaker inmates, marijuana use, sexual activ- ity, and gambling.

m

During the follow- ing decades, institutional reformers such as Doro- thea Dix sought to make jails and almshouses more humane.

m

In the criminal justice system, the disposition of offenders varies, not just by jurisdiction but also by type of offense. Those who have not been convicted of violent offenses and who have no previous criminal record are likely to be granted probation. Those who have been convicted of offenses under local or state jurisdiction may be jailed or imprisoned in facilities that have often been determined to violate minimal humane stan- dards of care. Federal convicts, on the other hand, may be incarcerated in prisons that are quali- tatively better, some of which have a decidedly pleasant ambiance.

m

Incarceration as the intervention of choice for young offenders continued to be a source of dis- pute within juvenile justice. Early proponents of boot camps, for example, promised that discipline, exercise, and routine would deter adolescents from future offenses

m

Juvenile justice is a significant feature of U.S. crim- inal justice for several reasons. Young deviants are good candidates for becoming adult deviants, in which case they become subject to the adult crim- inal justice system. Because the majority of adult offenders were also known to the juvenile justice system, it stands to reason that diverting youngsters from juvenile crime may well keep them out of the adult criminal justice system

m

Once incarcerated, mentally ill inmates pose problems that correc- tional officers are ill prepared to serve. Chicago and New York are just two cities with jails hous- ing thousands of mentally ill offender

m

inferior" to their law-abiding compatriots. Before World War II, the eugenics movement popularized the notion that deviant behavior had a genetic origin. Proponents of natural selection, some of them esteemed scientists and jurists, con- vinced state legislators to pass legislation allowing for involuntary sterilization of "mental defectives." By the mid-1950s, more than 58,000 mental patients and convicts had been forcibly sterilized.6 The practice of involuntary sterilization abated during the Civil Rights movement when it became recognized that many of the victims were women and minorities of color.

m

As more states began to address the problem, child welfare advocates built a compelling case for a national standard for child protective services. This lobbying led to the passage of the Child Abuse Prevention and Treatment Act (CAPTA) of 1974, which established the National Center for Child Abuse and Neglect (NCCAN) within the Department of Health and Human Services and presented a model statute for state child protective programs.

n

Increases in child abuse reports and decreases in expenditures led to a crisis in child welfare ser- vices.

n

Although the Supreme Court would rule that the guidelines were advisory, not mandatory, their decision was consistent with the new penology, because the purpose of criminal justice was not to arbitrate punishment in relation to lawlessness but to incapacitate large numbers of high-risk offenders selectively.

o

Direct-to-consumer advertising (DTCA) is the promotion of prescription drugs through newspa- per and magazine ads, brochures, videos, televi- sion commercials, and Internet marketing targeted at consumers and doctors. By 2013, spending on advertising stood at $8 billion.91 The only two developed countries where DTCA is currently legal are the United States and New Zealand, and in lim- ited form in Canada

t

Following this logic, the association between incarceration, social disadvantage, and dropping out of high school is striking. "More than half of all black men without a high school diploma go to prison at some time in their lives,"

t

From 1980 to 1990 alone, the cost of physicians' services rose by 300 percent

t

Guns and cars are the leading causes of non-medical deaths in the

t

Most health care costs in the United States are paid for by private insurers, public plans, and the direct public provision of health care

t

Not only are there no mechanisms to effectively control rising drug costs, but the new drug benefit means much larger sales volume

t

One of the knottiest issues in health policy is gun violence. There are about 300 million guns in the United States, and one-third of homes with chil- dren have guns

t

Removing the federal responsibility for provid- ing long-term cash assistance to the poor shifted the problem of poor support away from social welfare and into labor policy.

t

Specifically, many younger and healthier workers will opt for the HSA, leaving the older and sicker employees in tra- ditional health insurance plans. Drawing healthier workers out of health care plans will likely raise the cost of health insurance for those that remain. Con- servatives claim HSAs encourage people to more closely monitor their health care spending, and it therefore brings down medical costs

t

Sweden—historically considered a progressive welfare state—has frequently used labor policy as a proxy for aggressive public assistance programs.

t

The National Center for Health Statistics (NCHS) is a key resource of information about the health of Americans.

t

The SMI program is financed by beneficiary payments and contributions from general tax rev- enues

t

The U.S. criminal justice system is similar to educa- tion, and mental health programs in that states and localities provide a significantly larger portion of services than the federal government. The Consti- tution reserves public functions to the states unless they are ceded to the federal government; in the case of criminal justice, this means that state and local government expenditures exceed those of the federal government by a factor of four

t

The United States is the only major industrialized country that does not provide health cov- erage for all its citizens.

t

The diagnosis of a serious new health condi- tion, including cancer, diabetes, heart attack, chronic lung disease, or stroke, reduced the wealth of uninsured households by 20 percent. Insured households with a similar diagnosis suffered a 2 percent decline in overall wealth.

t

The economic giddiness of the middle 1990s reinforced the conservative belief that a job existed for anyone that wanted it. It was in this climate that the PRWORA was passed.

t

The poor are three times more likely to be uninsured as those who are not poor

t

The transition from public assistance to labor policy does not bode well for the "hard to employ," a group of recipients that have significant barriers to employment and difficulty in finding and sustaining work. Some of these barriers include substance abuse, physical disabilities, domestic violence, learning disabilities, mental health issues, language problems, chronic health problems, and multiple other barriers.

t

The uninsured are more likely than the pri- vately insured to not receive needed medical care and more likely to need hospitalization for avoidable acute conditions like pneumonia or uncontrolled diabetes. They are also more likely to rely on emergency room services or to have no regular source of care

t

There are no federal programs for childless adults who are poor but not disabled.

t

They are more likely to be contacted by a collection agency for overdue medical bills.

t

They are more likely to put off seeking care,to not receive care when needed, and to notfill a prescription or get treatment because of the expense

t

Uninsured adults hospitalized for heart attacks are 25 percent more likely to die while in the hospital than privately insured adults

t

Uninsured children have a higher instance of developmental delays than those with health coverage

t

What has helped keep drug prices high is the refusal of FDA to allow the importation of lower cost drugs from Canada and elsewhere

t

When the poor exhaust time-limited public assistance benefits they become a labor market rather than a welfare problem. With that change, U.S. public assistance policy became a short-term, transitional step in the march toward the full labor market participation of the poor.

t

Young adults (19 to 25 years old) were the least likely of any age group to have health insurance in 201

t

conservative welfare reformers conceded that terminating benefits would probably worsen deprivation but argued that stopping benefits was necessary.

t

the HI program is financed primarily through a mandatory payroll tax for all employed and self-employed people.

t

Types of illegal substances vary considerably. Next to marijuana, cocaine is the most prevalent illicit drug, accounting for 1.5 million users; heroin is far less prev- alent with 323,000 addicts.86 Even if heroin is less prev- alent, it remains a major problem if only because of the health problems associated with its use: As many as 25 percent of people who contract AIDS in this country are intravenous drug users (IDUs).

v

What is missing in our system today are modern, long-term treat- ment facilities where the chronically mentally-ill can receive good medical attention and, if neces- sary, can live safely until they can be moved to less restrictive facilities."

v

he federal response to illicit drug use has been twofold, involving both interdicting the supply of illegal substances and reducing the demand through treatment and public education. Government strate- gies have oscillated wildly between the interdiction and prevention approaches. Before the Reagan presi- dency, federal policy emphasized treatment and pub- lic education, assuming that these strategies would diminish demand. During the early 1970s, for exam- ple, two-thirds of federal appropriations for drug abuse were for treatment and education. A decade later, however, supply interdiction had superseded demand reduction as the prime strategy, consuming 80 percent of federal drug funds.

v

Although Medicare provides important ser- vices, the gaps in coverage are extensive, which is why many beneficiaries opt for HMOs or supple- ment Medicare with private Medigap insurance.

vb

Although the drug industry maintains that DTCA helps educate consumers, critics argue that the ads are emotional and are mis- leading since they understate adverse side-effects. Studies reveal that consumers who have watched DTCA ads will often request (and be prescribed) expensive brand-name drugs as opposed to generic

y

Beneficiaries without private supplemental coverage pay for charges not covered by Medicare and for various cost-sharing aspects of both HI and SMI. These charges may be paid by beneficiaries out-of-pocket, by a third party (an employer-sponsored retiree health plan or private "Medigap" insurance), or by Medicaid, if the person is eligible. "Medigap" insurance refers to private insurance plans that cover most of the Medicare co-pays

y

Medicaid is a federal/state program. States determine eligibility within broad federal guide- lines

y

Medicaid is a means-tested public assistance program. Eligible people receive services from physicians who accept Medicaid patients (often a minority of physicians) and other health care providers. These providers are reimbursed by the federal government on a per-patient basis.

y

The Australian health care system is a hybrid public-private sys- tem.

y

employers may be reluctant to hire people with high-risk conditions because of the negative impact on insurance premiums.

y

former President Lyndon Johnson signed into law the Medicaid and Medicare programs in 1965.34 Replacing all pre- vious governmental health programs, Medicaid became the largest public assistance program in the nation.

y

the number of Afri- can American children available for adoption far outstrips the number of African American families able to adopt children, despite the fact that Afri- can American families "adopt at a rate 4.5 times greater than white or Hispanic families.

y