THE EFFECTS OF ORGANIZATIONAL FORM IN THE MIXED MARKET FOR FOSTER CARE

ABSTRACT ** : This paper uses proprietary quality of care data to examine the consequences of organizational form in privatized US foster care services. The contract failure hypothesis generically proposes that nonprofits should provide higher quality services, relative to for‐profits, when output is costly to observe. Advocates argue that the nonprofits offer important consumer protections when public services are contracted to private agencies. Contrary to expectations, we find that nonprofit firms do not offer higher quality services. We explore the possibility that monitoring efforts by state regulators or competition among foster care agencies effectively mitigate the influence of organizational form in this particular mixed market.     

Private pay clients in adult day services

Data collected for all 3,992 participants in Maryland's adult day care programs as of December 31, 1993 showed that the majority of clients were supported by publicly supported "welfare" funding sources. The authors examined the differences in characteristics and service needs between the public payer population and private pay patients, including those who were charged on a sliding scale. They found that private pay clients were not dependent on others to "initiate service arrangements when they want and can find them." Private pay clients were twice as likely to be self or family referrals and more likely to be older, white, and living with a spouse or adult child. Private pay patients were also much more likely to have a history of the recent onset of cognitive impairment and associated memory loss but less likely to fall into the more ADL dependent categories. The nuclear families of private pay clients who are primary caregivers are described as the "critical marketing targets" and that services specifically for the cognitively impaired should be developed.     

Means‐Tested Long‐Term Care and Family Transfers

One of the pervasive problems with means‐tested public long‐term care programs is their inability to prevent individuals who could afford private long‐term services from taking advantage of public care. They often manage to elude the means‐test net through ‘strategic impoverishment’. We show in a simple model how this problem comes about, how it affects welfare and how it can be mitigated.     

ON GOODS AND SERVICES

The paper is concerned with the concept, definition and measurement of a service. Although services are often dismissed as immaterial goods, they are not special kinds of goods and belong in a quite different logical category from goods. The search for appropriate units of quantity in which to measure services is not an idle metaphysical pursuit. Without quantity units there can be no prices, and most economic theory becomes irrelevant. Indeed, large parts of economic theory may be irrelevant to the analysis of services anyway, precisely because they are not goods which can be exchanged among economic units. Services are as important as goods in modern developed economies and they need to be identified and quantified properly if the measurement of economic growth and inflation is to have any meaning for the economy as a whole. The concept of a service is explained in some detail in the paper, and various ways in which services can be classified for purposes of economic analysis are elaborated. The distinction between private and public goods, or rather between private and collective services, is re-examined in the light of the general concept of a service proposed in the paper. Externalities are shown to be simply special kinds of services.     

Perceived quality of public services, liquidity constraints, and the demand of private specialist care

In this article we offer direct evidence on the role of perceived quality differences in publicly provided health care services, in determining the incentive to opt out for private services and, for poor individuals, short-run credit constraints in the access to these services. We concentrate on private specialist care, a category of services for which disparities in the access are highest. We use Bank of Italy—SHIW data to first study the determinants of demand for private and public specialist care, estimating probit and bivariate probit models, and ZIP models. We then apply the Carneiro–Heckman procedure to identify the share of people constrained and study how perceived quality of public services affects the percentage of people short run constrained. Our estimates suggest the presence of large territorial differences, as for the role of income and the quality of public services.     

The Use and Cost of Child Care in Australia

The use and cost of child care have become important policy issues with rising labour force participation for women responsible for young children. In this article it is shown that for children aged less than 2 informal care is much more important than formal care. For children aged 3 to 5 by far the most important, and cheapest, form of formal care is preschool. The category of formal care which has expanded most rapidly is child care centre places. However the recent expansion of female employment has been effected with no rise in the share of formal care in the total. Publicly supplied child care centre places are over 40 per cent more expensive to produce than private ones. It is argued that for those who do not receive a fee relief subsidy public care is more expensive than private care. The inference is drawn that people are willing to pay more for public than private care because public care is of higher quality. However those buying this higher quality care pay (at most) only 80 per cent of the cost of producing the care. The shortage of care in the public sector is not solved by private sector expansion because users of care are not willing to pay the price of producing high quality care.     

Can't buy me love? Subsidizing the care of related children

This paper uses a reform in Illinois that reduced the monthly subsidy offered to relatives asked to provide foster care as a plausibly exogenous change in the cost of caring for related children. Families offered a 30% lower wage were 15% less likely to provide care, with especially large declines for children who require mental health services, infants and teenagers. One innovation is a sample selection model that uses the foster care placement tendency of child protection investigators to predict entry into the sample—an instrument that should be unrelated to family characteristics due to a rotational assignment process that effectively randomizes investigators to families. Meanwhile, child health, education, and placement outcomes do not appear to suffer following the decline in the subsidy offer, consistent with similar quality levels among marginal kin and non-kin caregivers.     

Saving the public from the private? Incentives and outcomes in dual practice

We consider a monopoly physician offering free public treatment and, if allowed, a private treatment for which patients have to pay out of pocket. While patients differ in the propensity to benefit from private treatment it always yields better health outcomes than public treatment but is also more costly in terms of money and time. We study the physician's supply of private care and allocation of time costs across public and private patients and contrast these with the first‐best allocation. To increase the willingness‐to‐pay for private treatment the physician shifts time costs to public patients. While this turns out to be socially optimal, the resulting positive network effect leads to an over‐provision of private care if time costs are sufficiently high. A second‐best allocation arises when the health authority sets public reimbursement but has no control over private provision. Depending on the welfare weight the health authority attaches to physician profits, a ban of dual practice may improve on the second‐best allocation. Notably, a ban benefits not only public patients but also private patients with a moderate propensity to benefit from private care.     

Microfinance and child mortality

Microfinance institutions (MFIs) offer targeted opportunities for the poor to generate additional income with a range of financial services including credit, insurance, savings accounts and money transfers. Aside from reducing poverty, microfinance can potentially improve health because it is the poor who are usually more constrained from health investments due to limited budgets. Furthermore, microfinancing specifically targets women, who are more likely to spend additional income on children’s well-being. Finally, several MFIs have also begun to offer health-related services, such as health education, health-care financing, clinical care, training community health workers, health micro-insurance and linkages to public and private health providers. Using a new data set, this article conducts the first multi-country study of the effect of microfinance on child mortality, the health outcome, which is most sensitive to the effects of absolute deprivation. Our findings confirm that an increase in the proportion of MFI clients in a country is significantly associated with lower under-five and infant mortality rates. We conclude that if MFIs’ educational and health services have indeed caused improvements in health outcomes at the community level, then it may be important for governments to complement these activities with similar campaigns, particularly in remote areas where MFI penetration is low.     

THE PROVISION OF LOCAL PUBLIC SERVICES THROUGH MIXED ENTERPRISES: THE ITALIAN CASE

ABSTRACT ** :  The rules regulating the creation of mixed enterprises companies (public-private companies) for the provision of local public services have been subjected, in Italy, to a rather complex evolution over time. The new rules introduced allow the creation of a mixed private public enterprise, with either public or private majority; in any case the private shareholder must be selected through a public tender procedure. The data seems to show that mixed enterprises have been used by municipalities as a tool that allows the exploitation of economies of scale and of scope, without necessarily losing control of the leadership and direction of the local utility. Better flexibility of mixed enterprises is also shown by the proportion of mixed enterprises acting outside the territory which is higher than the proportion of public enterprises similarly engaged. Moreover the presence of multi-service units is proportionally higher in mixed enterprises.     

Post-Lange Market Socialism: An Evaluation of Profit-Oriented Proposals

In recent years we have observed significant growth in the private sector in many higher education systems around the globe. This growth of private higher education is associated with high political expectations, notably concerning greater choice of programs and greater responsiveness of institutions to students' and labor markets' demands. Looking at the experience of several European and Latin American countries, this study analyzes the patterns of program diversification of public and private higher education and discusses the impact of the private sector for the diversification of higher education's supply. The results show a contrasting picture between political beliefs about privatization in higher education and its actual results, suggesting that private institutions tend to be far more specialized than their public counterparts.     

健康投资的产业结构效应:来自OECD等国家的宏观证据

在"未富先病"以及"健康中国"的背景下,文章从产业结构出发,通过使用世界银行数据库和佩恩表1995-2011年百余个国家的面板数据,研究了健康投资行业的发展对经济结构的影响,以期为当下中国转型经济结构的时代诉求提供参考.研究结果显示:首先,发展健康投资行业有助于增加服务业就业人口比重,并且私人健康投资对增加服务业就业人口比重的影响系数大于公共健康投资;其次,相对于公共健康投资,私人健康投资对第二产业增加值的挤出效应更有限;第三,发展健康服务业,尤其是公共健康事业将加快经济结构转型速度.综上所述,发展健康产业对推进产业结构转型具有积极意义,但如何在政策效果和可能的阻力之间进行权衡还需要政策制定者的慎重考虑.     

Impact of AIDS on Family Composition,Welfare, and Investment: Evidence from Uganda*

Although availability of quantitative information on the extent of HIV/AIDS in Africa is improving, the socio‐economic implications of the epidemic remain poorly understood. This paper explores this issue for Uganda focusing on households who received foster children between 1992 and 2000, a phenomenon that affected more than 15% of households. The authors find that addition of a foster child resulted in significant reductions of per capita consumption, income, and household investment which were more pronounced for the poor. Initial disadvantages in foster children's access to education for this group were overcome in the course of UPE implementation, while new inequalities have emerged in access to health services. Foster children's ability to access services will thus be affected by the broader policy environment as well as programs more specifically targeted at this group.     

Does health insurance matter? Evidence from China’s urban resident basic medical insurance

In 2007, China launched a subsidized voluntary public health insurance program, the Urban Resident Basic Medical Insurance (URBMI), for urban residents without formal employment. We estimate the impact of the URBMI on health care utilization and expenditure by a fixed effects approach with instrumental variable correction, using the 2006 and 2009 waves of the China Health and Nutrition Survey. We explore the time variation of program implementation at the city level as the instrument for individual enrollment. We find that this program has significantly increased the utilization of formal medical services, including both outpatient care and inpatient care, but it has not reduced total out-of-pocket health expense. We also find that this program has improved medical care utilization more for children, members of the low-income families, and the residents in the relatively poor western region.     

PUBLIC VERSUS PRIVATE DELIVERY OF MUNICIPAL SOLID WASTE SERVICES: THE CASE OF NORTH CAROLINA

This paper examines the effects of different institutional arrangements and characteristics on cost savings, efficiency gains, and productivity of delivering municipal solid waste services. A cost function approach is employed, and North Carolina municipal data for three years (1997, 2001, and 2003) are used for the analysis. Empirical findings indicate that there is no significant difference in cost savings between public delivery and private contractor delivery of solid waste services, a finding similar to those of other recent studies. There are three possible reasons for this. First, the threat of competition and contracting out might have led to cost savings in the cases of public delivery. Second, there might be a lack of competition because a few large private contractors have been able to win follow‐on contracts over the years. Third, there might be substantial transaction costs arising as the result of private contracting. (JEL H40, H83, Q53)     

Agri-environmental policies in the EU and United States: A comparison

Agri-environmental policies (AEPs) in the United States and the European Union are examples of payments for environmental services that pay farmers to reduce the negative externalities of agricultural production, while serving as a means to transfer public funds to farmers. We show that despite similar origins, AEPs in the two regions differ both in their specific objectives and in their implementation. For example, AEPs in most member states of the EU-15 have the additional objective of using agriculture as a driver for rural development. This objective is achieved by compensating farmers for the private delivery of positive public goods, such as attractive landscapes, produced by agriculture. The rationale is market failure, and there is empirical evidence that Europeans are willing to pay for such positive externalities. No comparable provision exists in U.S. policy. By contrast, U.S. AEPs focus almost entirely on reducing agriculture's negative externalities, such as soil erosion. Second, we find that U.S. programs are more targeted than their EU counterparts, and take opportunity cost into account. The EU programs, on the other hand, address a wider range of externalities, and are focused more on the paying for a particular farming process than reducing specific negative externalities. The EU takes a broader view of AEPs than does the United States, both in terms of type of activity that can be funded, and by using less targeting by land characteristics, and so the European program could be more easily used as a mechanism for transferring income to producers. Despite this, we find evidence that many of the amenities targeted by the programs are demanded by the population.     

THE HOUSEHOLD DISTRIBUTION OF GOVERNMENT SERVICES FOR AGRICULTURE AND EDUCATION IN PENINSULAR MALAYSIA IN 1974

The paper reports on several results from a comprehensive study of the household incidence of public expenditure in Peninsular Malaysia in 1974. The results for education show a pro-poor distribution of expenditure when measured as a share of household income. Using however the criterion of each according to his needs (that is the number of school-age children per household) reverses this outcome. In agriculture, because of the importance of land settlement, benefits from public expenditure distribute predominantly in favor of the poor.
The research differs from the usual study of this kind in that individual government outputs such as school years, or fertilizer loans, were defined, and in the case of education their unit costs estimated and their distribution across households measured. In the case of education, both the costs of services from capital and the households' out-of-pocket educational costs were added to the current subsidies. As one consequence, it was seen that total expenditure for education in Malaysia exceeds one-eighth of GNP, nearly double the conventional estimate. Equally important, for the poor the burden of private costs for education even within a public system were seen to be very high.
The contrasts between the strong results for education, a broad based social service, and the less conclusive results for agriculture, an economic service which impacts directly on production, were instructive in suggesting the limitations of such research in measuring the effects of government budget activity on distribution.     

MEASURING QUALITY IN SOCIAL CARE SERVICES: THEORY AND PRACTICE

ABSTRACT 1 : Measuring and assessing service quality in the social care sector presents distinct challenges. The ‘experience’ good properties of social care, for instance, and the large influence played by subjective judgements about the quality of personal relationships between carer and user and of process‐related service characteristics make it difficult to develop indicators of service quality, including those of service impact on final outcomes. Using some of the key features of the ‘Production of Welfare’ approach, the paper discusses recent developments in the UK of the theoretical and practical frameworks used for assessing quality in social care and for understanding the final impact of services on the wellbeing of their recipients. Key current and future challenges to the development of such frameworks include difficulties in disentangling the impact of social care services on final outcomes from the often dominating effects of other, non‐service related factors, and the generalization of consumer‐directed care models and of the ‘personalization’ of care services. These challenges are discussed in the context of the different possible applications of quality indicators, including their role as supporting the service commissioning process and their use for assessing the performance of service providers.     

Regulating Providers' Reimbursement in a Mixed Market for Health Care

Hospitals can be reimbursed for their costs in many ways. Several authors have investigated the effects of these reimbursement rules on physician incentives and, therefore, on the quantity of services provided to patients. A form of (linear) cost-sharing tends to emerge as the socially efficient reimbursement policy. We present a model of hospital reimbursement, based on Ellis and McGuire (1986). The new feature is that physicians can supply private health care services to a patient, as well as public sector ones; a common institutional arrangement in many health care systems. We investigate the optimal public sector reimbursement rule given that private market incentives must now be taken into account. Public sector cost-sharing remains socially efficient, but it is generally non-linear: the precise details depend on whether public and private services are substitutes or complements and on the degree of social efficiency achieved in the private sector. Other reimbursement schemes exhibit optimality properties not present in Ellis and McGuire's work.