THE IMPLEMENTATION OF FEDERAL FAMILY PLANNING POLICY: AN ANALYSIS OF FACTORS AFFECTING STATE EXPENDITURES, FISCAL YEARS 1976-1981 (WOMEN, BUDGET, POPULATION)

The purpose of this study was to analyze the implementation of national family planning policy in the United States, which was embedded in four separate statutes during the period of study, Fiscal Years 1976-81. The design of the study utilized a modification of the Sabatier and Mazmanian framework for policy analysis, which defined implementation as the carrying out of statutory policy. The study was divided into two phases. The first part of the study compared the implementation of family planning policy by each of the pertinent statutes. The second part of the study identified factors that were associated with implementation of federal family planning policy within the context of block grants.^ Implemention was measured here by federal dollars spent for family planning, adjusted for the size of the respective state target populations. Expenditure data were collected from the Alan Guttmacher Institute and from each of the federal agencies having administrative authority for the four pertinent statutes, respectively. Data from the former were used for most of the analysis because they were more complete and more reliable.^ The first phase of the study tested the hypothesis that the coherence of a statute is directly related to effective implementation. Equity in the distribution of funds to the states was used to operationalize effective implementation. To a large extent, the results of the analysis supported the hypothesis. In addition to their theoretical significance, these findings were also significant for policymakers insofar they demonstrated the effectiveness of categorical legislation in implementing desired health policy.^ Given the current and historically intermittent emphasis on more state and less federal decision-making in health and human serives, the second phase of the study focused on state level factors that were associated with expenditures of social service block grant funds for family planning. Using the Sabatier-Mazmanian implementation model as a framework, many factors were tested. Those factors showing the strongest conceptual and statistical relationship to the dependent variable were used to construct a statistical model. Using multivariable regression analysis, this model was applied cross-sectionally to each of the years of the study. The most striking finding here was that the dominant determinants of the state spending varied for each year of the study (Fiscal Years 1976-1981). The significance of these results was that they provided empirical support of current implementation theory, showing that the dominant determinants of implementation vary greatly over time. ^

Implementation analysis of the Texas Vendor Drug Program

An agency is accountable to a legislative body in the implementation of public policy. It has a responsibility to ensure that the implementation of that policy is consistent with its statutory objectives.^ The analysis of the effectiveness of implementation of the Vendor Drug Program proceeded in the following manner. The federal and state roles and statutes pursuant to the formulation of the Vendor Drug Program were reviewed to determine statutory intent and formal provisions. The translation of these into programmatic details was examined focusing on the factors impacting the implementation process. Lastly, the six conditions outlined by Mazmanian and Sabatier as criteria for effective implementation, were applied to the implementation of the Vendor Drug Program to determine if the implementation was effective in relation to consistency with statutory objectives.^ The implementation of the statutes clearly met four of the six conditions for effective implementation: (1) clear and consistent objectives; (2) a valid causal theory; (3) structured the process to maximize agency and target compliance with the objectives; and (4) had continued support of constituency groups and sovereigns.^ The implementation was basically consistent with the statutory objectives, although the determination of vendor reimbursement has had and continues to have problems. ^

Analytical frame for public policy implementation

"I don't think we truly understand how to implement. What does it mean to truly implement? Not the command center type that our culture is very good at, but a thorough planned systematic approach" (HP, 9.28.2011). This important question is asked by a clinician who works in a health care setting and who has experienced the implementation of a public policy. This case study applied the lessons learned from three generations of public policy research to a health care setting. As a result of the study an analytical frame was created as a guide to assess an organization's readiness for the implementation of a public policy.^

SUPERFUND: AN ANALYSIS OF IMPLEMENTATION FAILURE (CERCLA, HEALTH LAW POLICY)

In December, 1980, following increasing congressional and constituent-interest in problems associated with hazardous waste, the Comprehensive Environmental Recovery, Compensation and Liability Act (CERCLA) was passed. During its development, the legislative initiative was seriously compromised which resulted in a less exhaustive approach than was formerly sought. Still, CERCLA (Superfund) which established, among other things, authority to clean up abandoned waste dumps and to respond to emergencies caused by releases of hazardous substances was welcomed by many as an important initial law critical to the cleanup of the nation's hazardous waste. Expectations raised by passage of this bill were tragically unmet. By the end of four years, only six sites had been declared by the EPA as cleaned. Seemingly, even those determinations were liberal; of the six sites, two were identified subsequently as requiring further cleanup.^ This analysis is focused upon the implementation failure of the Superfund. In light of that focus, discussion encompasses development of linkages between flaws in the legislative language and foreclosure of chances for implementation success. Specification of such linkages is achieved through examination of the legislative initiative, identification of its flaws and characterization of attendant deficits in implementation ability. Subsequent analysis is addressed to how such legislative frailities might have been avoided and to attendant regulatory weaknesses which have contributed to implementation failure. Each of these analyses are accomplished through application of an expanded approach to the backward mapping analytic technique as presented by Elmore. Results and recommendations follow.^ Consideration is devoted to a variety of regulatory issues as well as to those pertinent to legislative and implementation analysis. Problems in assessing legal liability associated with hazardous waste management are presented, as is a detailed review of the legislative development of Superfund, and its initial implementation by Gorsuch's EPA. ^

The interorganizational implementation of state health policy: A network approach

This is an implementation analysis of three consecutive state health policies whose goal was to improve access to maternal and child health services in Texas from 1983 to 1986. Of particular interest is the choice of the unit of analysis, the policy subsystem, and the network approach to analysis. The network approach analyzes and compares the structure and decision process of six policy subsystems in order to explain program performance. Both changes in state health policy as well as differences in implementation contexts explain evolution of the program administrative and service unit, the policy subsystem. And, in turn, the evolution of the policy subsystem explains changes in program performance. ^

Health care policy analysis of Medicaid's early and periodic screening, diagnosis, and treatment (EPSDT) benefit in Colorado

The purpose of this thesis is to identify "best practice" recommendations for successful implementation of the EPSDT outreach program at Memorial Health System's Hospital for Children in Colorado Springs through a policy analysis of Medicaid EPSDT services in Colorado. A successful program at Memorial will increase education and awareness of EPSDT services, enrollment, and access to and utilization of health care services for eligible children. Methodology utilized in this study included questionnaires designed for the EPSDT contract administrator and outreach coordinators/workers; analysis of current federal and state policies; and studies conducted at the federal and state level, and by various advocacy groups. The need for this analysis of EPSDT came about in part through an awareness of increasingly high numbers of children in poverty and who are uninsured. Though the percentage of children living in poverty in Colorado is slightly below the national average (see Table 2), according to data analyzed by The Annie E. Casey Foundation, the percentage of children (0-18) living in poverty in Colorado increased from 10% in 2000 to 16% in 2006, a dramatic increase of 60% surpassed by only one other state in the nation (The Annie E. Casey Foundation, 2008). By comparison, the U.S. percentage of children in poverty during the same time frame rose from 17% to 18% (The Annie E. Casey Foundation, 2008). What kind of health care services are available to this vulnerable and growing group of Coloradans, and what are the barriers that affect their enrollment in, access to and utilization of these health care services? Barriers identified included difficulty with the application process; system and process issues; a lack of providers; and a lack of awareness and knowledge of EPSDT. Fiscal restraints and legislation at the federal and state level are also barriers to increasing enrollment and access to services. Outreach services are a critical component of providing EPSDT services, and there were several recommendations regarding outreach and case management that will benefit the program in the future. Through this analysis and identification of a broad range of barriers, a clearer picture emerged of current challenges within the EPSDT program as well as a broad range of strategies and recommendations to address these challenges. Through increased education and advocacy for EPSDT and the services it encompasses; stronger collaboration and cooperation between all groups involved, including providing a Medical Home for all eligible children; and new legislation putting more money and focus on comprehensive health care for low-income uninsured children; enrollment, access to and utilization of developmentally appropriate and quality health care services can be achieved. ^

An analysis of the RightCare policy at Ben Taub General Hospital, Houston, Texas

Introduction. This study is a two-part evaluation of the RightCare policy, a policy implemented to reduce crowding at the Emergency Center (EC) at Ben Taub General Hospital in Houston, Harris County, Texas. This research includes an evaluation of the policy's impact on specific hospital measures, along with a description of the policy's demise from the point of view of hospital staff. Objective. The purpose of this study is two-fold: (1) To determine whether RightCare policy affected the level of crowding in the Emergency Center and (2) to identify the conditions that may have led to the policy's demise. Methods. For the policy impact portion of this research, hospital measures were collected from existing databases. Analysis included a pre-post comparative design in which the 12 months preceding the policy's implementation were compared with the 12 months following the policy's implementation. For the policy perception portion, employees were surveyed using an on-line questionnaire. Results. The results of the study are mixed. Some measures improved, including time spent on ambulance diversion and the proportion of those who left without being seen, while others did not, such as return visits and total length of stay. Employees generally supported the policy, but expressed concerns over insufficient training and funding. Conclusion. The RightCare policy was a good initial attempt to improve crowded conditions in the EC. The study showed that a clearer policy design, improved training, adequate staffing levels, and better communication would improve operational outcomes in the future.^

The emergence of the social determinants of health on the policy agenda in Britain: A case study, 1980--2003

Numerous theories have been advanced in the effort to explain how a given policy issue manages to take root in the public sphere and subsequently move forward on the public legislative agenda—or not. This study examined how the social determinants of health (SDOH) came to be part of the legislative policy agenda in Britain from 1980 to 2003. ^ The specific objectives of the research were: (1) to conduct a sociopolitical analysis grounded in alternative agenda-setting theories to identify the factors responsible for moving the social determinants health perspective onto the British policy agenda; and (2) to determine which of the theories and related dimensions best accounted for the emergence of this perspective. ^ A triangulated content and context analysis of British news articles, historical accounts, and research commentaries of the SDOH movement was conducted guided by relevant agenda-setting theories set within a social movement framework to chronicle the emergence of the SDOH as a significant policy issue in Britain. ^ The most influential social movement and agenda setting elements in the emergence of the SDOH in Britain were issue generation tactics, framing efforts, mobilizing structures, and political opportunities grounded in social movement and agenda setting theories. Policy content or the details of the policy had comparatively little impact on the successful emergence of the SDOH. Despite resistance by the government, from 1980 to 1996 interest groups created a political understanding of the SDOH utilizing a framing package encompassing notions of inequality, fairness, and justice. This frame transmitted a powerful idea connected to a core set of British values and beliefs. After 1996, a shift in political opportunities cemented the institutional arrangements needed to sustain an environment conducive to the development and implementation of SDOH policies and programs. ^ This research demonstrates that the U.S. emergence of the SDOH on the policy agenda will depend upon: (1) U.S. ideals and values regarding poverty, inequality, race, health, and health care that will determine issue framing; (2) political opportunities that will emerge—or not—to advance the SDOH policy agenda; and (3) the mobilizing structures that support or oppose the issue. ^

Policy analysis of the Americans with Disabilities Act of 1990 and federal funding concerning barrier-free playgrounds

The Americans with Disabilities Act (ADA) of 1990 was created to prohibit discrimination against disabled persons in our society. The goal of the ADA as a comprehensive civil rights law is to "ensure equal opportunity and complete participation, independent living and economic self-sufficiency" for disabled persons (U.S. Department of Justice, 2008). As part of Title II and III of the ADA, states and local governments are required to provide people with disabilities the same chance to engage in and benefit from all programs and services including recreational facilities and activities as every other citizen. Recreational facilities and related structures must comply with accessibility standards when creating new structures or renovating existing ones. Through a systematic literature review of articles accessed through online databases, articles relating to children with disabilities, their quality of life and their experience gained through play were reviewed, analyzed and synthesized. Additionally, the ADA's Final Rule regarding accessible playgrounds was evaluated through a descriptive analysis which yielded the following five components relating the importance of barrier-free playgrounds to children with disabilities: appropriate dimensions for children, integration of the play area, variety of activity and stimulation, availability of accessible play structures to communities, and financial feasibility. These components were used as evaluation criteria to investigate the degree to which the ADA's Final Rule document met these criteria. An evaluation of two federal funding sources, the Urban Parks and Recreation Renewal Program (UPARR) and the Land and Water Conservation Fund (LWCF), was also conducted which revealed three components relating the two programs' ability to support the realization of the ADA's Final Rule which included: current budget for the program, ability of local communities to attain funds, and level of ADA compliance required to receive funding. Majority of the evaluation of the Final Rule concluded it be adequate in development of barrier-free playgrounds although there are some portions of the guidelines that would benefit from further elucidation. Both funding programs were concluded to not adequately support the development of barrier-free playgrounds and therefore it was recommended that their funding be re-instated or increased as necessary. ^

A comparative analysis of CHIP Perinatal policy in twelve states

The purpose of this comparative analysis of CHIP Perinatal policy (42 CFR § 457) was to provide a basis for understanding the variation in policy outputs across the twelve states that, as of June 2007, implemented the Unborn Child rule. This Department of Health and Human Services regulation expanded in 2002 the definition of “child” to include the period from conception to birth, allowing states to consider an unborn child a “targeted low-income child” and therefore eligible for SCHIP coverage. ^ Specific study aims were to (1) describe typologically the structural and contextual features of the twelve states that adopted a CHIP Perinatal policy; (2) describe and differentiate among the various designs of CHIP Perinatal policy implemented in the states; and (3) develop a conceptual model that links the structural and contextual features of the adopting states to differences in the forms the policy assumed, once it was implemented. ^ Secondary data were collected from publicly available information sources to describe characteristics of states’ political system, health system, economic system, sociodemographic context and implemented policy attributes. I posited that socio-demographic differences, political system differences and health system differences would directly account for the observed differences in policy output among the states. ^ Exploratory data analysis techniques, which included median polishing and multidimensional scaling, were employed to identify compelling patterns in the data. Scaled results across model components showed that economic system was most closely related to policy output, followed by health system. Political system and socio-demographic characteristics were shown to be weakly associated with policy output. Goodness-of-fit measures for MDS solutions implemented across states and model components, in one- and two-dimensions, were very good. ^ This comparative policy analysis of twelve states that adopted and implemented HHS Regulation 42 C.F.R. § 457 contributes to existing knowledge in three areas: CHIP Perinatal policy, public health policy and policy sciences. First, the framework allows for the identification of CHIP Perinatal program design possibilities and provides a basis for future studies that evaluate policy impact or performance. Second, studies of policy determinants are not well represented in the health policy literature. Thus, this study contributes to the development of the literature in public health policy. Finally, the conceptual framework for policy determinants developed in this study suggests new ways for policy makers and practitioners to frame policy arguments, encouraging policy change or reform. ^

Employment outcomes in liver transplant recipients: A policy analysis

Liver transplantation is a widely accepted treatment for end stage liver disease. Research has shown that people with end-stage liver disease experience improved survival and health-related quality of life after transplantation. However, the unemployment rate among liver transplant recipients remains high. The reasons for this were the subject of a study that was used as the primary dataset for this policy analysis. According to the primary data and background supporting data, many transplant recipients remain unemployed for fear of losing needed healthcare and disability benefits. When employment is considered as a health outcome, it is important in an era of evidence based medicine to ensure that healthcare interventions such as liver transplantation produce improved health outcomes. Therefore, the high unemployment rate among liver transplant recipients is a poor health outcome that should be addressed. In this policy analysis, it is proposed that policy might affect this outcome. The problem of unemployment after liver transplantation is structured and policies affecting the problem are evaluated according to the validated criteria - Effectiveness, Equity, Efficiency, and Feasibility. A policy solution is proposed, evaluated, and ultimately recommended to effectively address the problem, to make healthcare coverage more equitable for liver transplant recipients, and to provide a more cost-effective healthcare coverage model during this time of healthcare crisis.^

A stakeholder analysis of the Texas Youth Commission issue for the Texas 80th Legislative Session

The following is a policy analysis based on the Advocacy Coalition Framework by Paul Sabatier. The study question was who were the stakeholders in the legislative process for the issue of the Texas Youth Commission (TYC) overhaul during the Texas 80th Legislative Session. This analysis included the stakeholders identifying characteristics including beliefs and interests, goals and resources, and finally, the winning legislative solutions as embodied in three bills that were passed. The study linked the stakeholders with three bills and expanded on the literature for the stakeholder group of Policy Brokers. The conclusions were that all stakeholders including Youth Advocates, the Policy People and Policy Brokers were effective in advancing legislative solutions to address the need for an agency overhaul of TYC and that the three new policies will be evaluated in the future as either short term change or long-term reforms based on their implementation. ^

Policy analysis of Texas Senate Bill 532 and the regulation of nurse practitioners in the convenience care model

Background. Retail clinics, also called convenience care clinics, have become a rapidly growing trend since their initial development in 2000. These clinics are coupled within a larger retail operation and are generally located in "big-box" discount stores such as Wal-mart or Target, grocery stores such as Publix or H-E-B, or in retail pharmacies such as CVS or Walgreen's (Deloitte Center for Health Solutions, 2008). Care is typically provided by nurse practitioners. Research indicates that this new health care delivery system reduces cost, raises quality, and provides a means of access to the uninsured population (e.g., Deloitte Center for Health Solutions, 2008; Convenient Care Association, 2008a, 2008b, 2008c; Hansen-Turton, Miller, Nash, Ryan, Counts, 2007; Salinsky, 2009; Scott, 2006; Ahmed & Fincham, 2010). Some healthcare analysts even suggest that retail clinics offer a feasible solution to the shortage of primary care physicians facing the nation (AHRQ Health Care Innovations Exchange, 2010). ^ The development and performance of retail clinics is heavily dependent upon individual state policies regulating NPs. Texas currently has one of the most highly regulated practice environments for NPs (Stout & Elton, 2007; Hammonds, 2008). In September 2009, Texas passed Senate Bill 532 addressing the scope of practice of nurse practitioners in the convenience care model. In comparison to other states, this law still heavily regulates nurse practitioners. However, little research has been conducted to evaluate the impact of state laws regulating nurse practitioners on the development and performance of retail clinics. ^ Objectives. (1). To describe the potential impact that SB 532 has on retail clinic performance. (2). To discuss the effectiveness, efficiency, and equity of the convenience care model. (3). To describe possible alternatives to Texas' nurse practitioner scope of practice guidelines as delineated in Texas Senate Bill 532. (4). To describe the type of nurse practitioner state regulation (i.e. independent, light, moderate, or heavy) that best promotes the convenience care model. ^ Methods. State regulations governing nurse practitioners can be characterized as independent, light, moderate, and heavy. Four state NP regulatory types and retail clinic performance were compared and contrasted to that of Texas regulations using Dunn and Aday's theoretical models for conducting policy analysis and evaluating healthcare systems. Criteria for measurement included effectiveness, efficiency, and equity. Comparison states were Arizona (Independent), Minnesota (Light), Massachusetts (Moderate), and Florida (Heavy). ^ Results. A comparative states analysis of Texas SB 532 and alternative NP scope of practice guidelines among the four states: Arizona, Florida, Massachusetts, and Minnesota, indicated that SB 532 has minimal potential to affect the shortage of primary care providers in the state. Although SB 532 may increase the number of NPs a physician may supervise, NPs are still heavily restricted in their scope of practice and limited in their ability to act as primary care providers. Arizona's example of independent NP practice provided the best alternative to affect the shortage of PCPs in Texas as evidenced by a lower uninsured rate and less ED visits per 1,000 population. A survey of comparison states suggests that retail clinics thrive in states that more heavily restrict NP scope of practice as opposed to those that are more permissive, with the exception of Arizona. An analysis of effectiveness, efficiency, and equity of the convenience care model indicates that retail clinics perform well in the areas of effectiveness and efficiency; but, fall short in the area of equity. ^ Conclusion. Texas Senate 532 represents an incremental step towards addressing the problem of a shortage of PCPs in the state. A comparative policy analysis of the other four states with varying degrees of NP scope of practice indicate that a more aggressive policy allowing for independent NP practice will be needed to achieve positive changes in health outcomes. Retail clinics pose a temporary solution to the shortage of PCPs and will need to expand their locations to poorer regions and incorporate some chronic care to obtain measurable health outcomes. ^

A comparative analysis of Texas and Louisiana Oil-field NORM Waste Policy

NORM (Naturally Occurring Radioactive Material) Waste Policies for the nation's oil and gas producing states have been in existence since the 1980's, when Louisiana was the first state to develop a NORM regulatory program in 1989. Since that time, expectations for NORM Waste Policies have evolved, as Health, Safety, Environment, and Social responsibility (HSE & SR) grows increasingly important to the public. Therefore, the oil and gas industry's safety and environmental performance record will face challenges in the future, about its best practices for managing the co-production of NORM wastes. ^ Within the United States, NORM is not federally regulated. The U.S. EPA claims it regulates NORM under CERCLA (superfund) and the Clean Water Act. Though, there are no universally applicable regulations for radium-based NORM waste. Therefore, individual states have taken responsibility for developing NORM regulatory programs, because of the potential radiological risk it can pose to man (bone and lung cancer) and his environment. This has led to inconsistencies in NORM Waste Policies as well as a NORM management gap in both state and federal regulatory structures. ^ Fourteen different NORM regulations and guidelines were compared between Louisiana and Texas, the nation's top two petroleum producing states. Louisiana is the country's top crude oil producer when production from its Federal offshore waters are included, and fourth in crude oil production, behind Texas, Alaska, and California when Federal offshore areas are excluded. Louisiana produces more petroleum products than any state but Texas. For these reasons, a comparative analysis between Louisiana and Texas was undertaken to identify differences in their NORM regulations and guidelines for managing, handling and disposing NORM wastes. Moreover, this analysis was undertaken because Texas is the most explored and drilled worldwide and yet appears to lag behind its neighboring state in terms of its NORM Waste Policy and developing an industry standard for handling, managing and disposing NORM. As a result of this analysis, fourteen recommendations were identified.^