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A comparative analysis of the level of financial effort exhibited in the states for financing mental retardation services was presented. States were ranked on a criterion (aggregate personal income) that compensated for differences in each state's financial capacity. During the FYs 1977-1984 period, on a nationwide basis, state governments spent increasingly more of their own funds for community services and increasingly less for institutional operations; however, combined institutional and community services spending was relatively stable. A hierarchical multiple regression analysis on three economic variables was performed: state size, wealth, and degree of federal assistance. All were very poor predictors of community services fiscal effort, implying the presence of more complex determinants of mental retardation spending. Degree of federal assistance was an important, inversely related, predictor of institutional fiscal effort.
Decentralization of public program administration and financing to subnational units of government is examined in the context of hospital and nursing home assistance programs in the United States. Do subnational governments (i.e., states) adapt service utilization controls and tighter program eligibility during periods of fiscal austerity? Are these actions affected by expenditure levels, state budget balances, tax revenues, and the state's proportion of low income persons? Published data covering the period 1978-1982 from each of the 50 U.S. states were analyzed using multiple regression. States with a low proportion of low-income persons and a high per capita tax base were likely to increase minimum income eligibility standards to keep pace with inflation. All other states, regardless of fiscal condition, tended toward more restrictive income standards. States were equally likely to adopt utilization controls for health and long-term care services regardless of state revenue or health expenditures.
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A brief history of the regulation of medical device software within the United States is presented, along with a discussion of the reasoning that the US Food and Drug Administration (FDA) presents for modifying the requirements for software regulation from those previously used for hardware devices. The current regulatory status is discussed for the two categories of medical device software, software used within medical devices and software used to produce or test medical devices. The published FDA documents which determine the current environment for the regulation of software are summarized and discussed. The two types of medical device software are related to the two areas of FDA regulation, good manufacturing practices and permission to sell medical devices. The expected direction of future medical device software regulation, and its relationship to the European Economic Community (EEC) and international markets is discussed.
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Fifty years ago health care was a private matter between a physician and his patient. Doctors practiced medicine; people could and did pay for their own health care; and legislators did not need to concern themselves much with health problems. In the meantime, instigated by a massive scientific knowledge explosion, we have spent billions on monstrous complexes to house ultramodern equipment and technology to fight acute, dreaded diseases. Doctors, who once treated human body as an entity, are so specialized that none seems to know any more that the head bone is still indirectly connected to the great toe. People, who incidentally are plagued with essentially the same chronic maladies that visited their predecessors five decades ago, are in real trouble if their complaint is simply a boil on the backside. First they must determine who specializes in this particular area. Next they are lucky if they can obtain an appointment before the boil bursts. Finally, they probably cannot afford to pay for the services rendered. The lawmaker steps in and pours more money into erecting more buildings and providing more specialists. We will not solve the dissonance between the mutually dependent group if we isolate ourselves, forgetting to listen, forgetting to educate, forgetting to communicate. Let me close with Sir William Osler's metaphor: How common the experience to enter a cold cheerless room in which the fire in the grate has died down, not from lack of coal, not because the coal was not alight, but the bits, large and small, falling away from each other have gradually become dark and cold. Break them with a poker, get them together, and what a change in a few minutes.