Thursday, May 31, 2007
Friday, May 25, 2007
At the Forum's Viewpoint Luncheon May 9, we had a panel of speakers representing the various health care reform plans now being batted about in Madison, as well as a speaker representing a more market-based view. All of the panelists agreed that costs (as well as access) are a problem and they all agreed that better information on cost and quality would benefit patients/consumers. But their opinions varied as to which policies would provide the best solutions, and even as to whether enacted legislation should be the default remedy.
What was missing from the conversation was the influence of practice: Can changes in how doctors practice lower costs? We've all heard by now about the experiment by Kaiser Permanente that found simple changes in hand-washing protocol resulted in fewer infections in patients. A post on the Wall Street Journal's health blog last week highlighted how a Utah health system dramatically reduced the number of babies needing costly newborn intensive care by postponing elective inductions of labor until 39 weeks gestation or later. And there's a relatively new book out by Maggie Mahar that controversially argues new and better medical equipment results in doctors eager to use new technology ordering tests merely because they can. From a Washington Monthly review of the book:
...[M]edicine is particularly vulnerable to perversions of Say’s Law, which states that supply creates its own demand. Diving into the data, Mahar relates Dartmouth researcher Jack Wennberg’s findings that the amount of care a patient receives is scarily dependent on where he lives. The more specialists, hospitals, and doctors you’ve got access to, the more surgeries, medicines, and treatments you’re likely to undergo. Worse, there’s no evidence that the outcomes differ between the two groups, and plenty of evidence that they don’t. Indeed, for those receiving the most intense care, the outcomes are worse—a predictable finding, considering the risk of complications, physician error, and infections.
The most effective changes in practice result from data analysis. Thus, transparency of data not only benefits us as consumers when we "shop" for care, but also as patients when a clinic, hospital, or health care system notices an unhealthy data trend and makes changes. But, no matter how transparent the data, savings will not occur unless the health care provider is willing to change its practices even if revenues could decrease in the long-run from healthier patients. That's were policy comes in. As health care becomes more profit driven, policies that provide incentives for cost-saving changes in practice may be needed.
The Milwaukee Journal Sentinel's Sunday Crossroads section May 20 included a roundtable discussion of health care experts. Two of these experts explicitly mentioned provider practices as an area in which improvement is needed, and the others made mention of better efficiency among providers. But efficiency is not the same concept. The doctors in Utah that were scheduling elective inductions probably believed they were being efficient by attempting to manage deliveries in a more predictable manner. Meanwhile, none of the doctors saw the deleterious and costly effects of the early inductions within their own patient groups; it was not until the administrators of the system put the data all together that the doctors became convinced their practices should change. And every hospital that operates its own array of high tech diagnostic equipment likely does so in the name of efficiency--and from the vantage point of a patient impatient for results, it is efficient. But it is costly, as well.
We are remiss when debating health care reform if we don't include policy, data transparency, and practice in our talking points. All three ingredients are necessary for reform to be made.
Thursday, May 24, 2007
Click on the following link to get a quick visual history of political fragmentation in the United States. By clicking on the link you will be treated to an animated map showing state and county boundary changes from 1643 to present. Focus your gaze on Wisconsin and watch our state get sliced and diced over time. It's interesting to see the increasingly smaller county unit creep from the southeastern corner of the state until they reached lake Superior years later.
The question is simple: do these historical boundaries match today's service delivery needs?
In some communities elsewhere, there have been city/county consolidations to better align taxpayer needs with a set of more workable political boundaries. According to one report, cost savings of such consolidations have been negligible. Given the huge political barriers to governmental consolidation, the shared services (i.e. cooperation) approach to dealing with political fragmentation has won some converts in southeastern Wisconsin. A Public Policy Forum report released in April of 2006 documented 145 shared service agreements in the seven county region among the 63 municipalities and counties that responded to our survey. We were pleasantly surprised at the extent and array of such services, but there is always room for greater cooperation, of course. It's imperative for our diced-up state to find more ways to come together.
Tuesday, May 22, 2007
When the sun rises in Hanoi, people in Wisconsin are putting their kids to bed. It may be worth pondering the symbolism that evokes -- because figuratively it certainly seems to be daybreak in Vietnam. That doesn't have to mean slumber for Milwaukeeans, but it's clear the optimism of a new day is easier to find half way across the world from us. That's an the early impression of our delegation of 18 Milwaukee civic leaders, most of whom returned from Vietnam on Sunday. The energy and entrepreneurial spirit in Hanoi makes it easy to understand why global economists are seeing Vietnam as the next Asian tiger, perhaps 15 years behind China but on the verge of explosive growth.
The idea of the week-long trip, organized by the Public Policy Forum and others, was for a diverse group of Milwaukeeans to explore possibilities for a lasting and productive relationship between Hanoi and Milwaukee. We'll regroup to discuss whether (and, if so, how) that might happen in a few days, but for now I think there are at least three likely outcomes: (1) a vehicle for Milwaukeeans to invest in Vietnam's growth and perhaps export products like machinery that an emerging country needs and our mature city makes; (2) a cultural exchange that could bring Vietnamese performing (and perhaps visual) arts here in Milwaukee and vice versa; and (3) one or more humanitarian projects that would link the sponsoring Rotary Club of Milwaukee with the needs of a country with extreme poverty. Stay tuned for more on this developing story.
Posted by Jeff Browne at 9:30 AM
Monday, May 21, 2007
It can be exhausting talking about growth all the time. Growth is in every speech, every report, every sound-bite, every strategic plan. I'm guilty as charged - grow the economy, grow the tax base, grow jobs, grow income, etc., etc., etc. Naturally, growth can be a good thing because it can have the effect of easing the tax burden and increasing personal wealth.
With all the talk of growth, can we equipped ourselves to embrace decline in our culture?
The idea that smaller is better is gaining traction within some communities in the long-decaying rust belt region of the upper Midwest. After all, say supporters of the nascent shrinking cities movement, why pay for expensive municipal services to support a 1950's population of 170,000, when currently only 82,000 live in the community (Youngstown, OH was used for this example). An example of "embracing decline" is to permanently cut off services to areas of a city that are largely vacant and no longer viable and then turn those tracks of land into low-maintenance prairie.
If you are interested in the subject of urban decay, I would recommend the DetroitYes website as a required layover when surfing the web for decline information. The site has an astonishing collection of photo's from modern-day Detroit in all it's crumbling glory. The above photo, from the DetroitYes collection, is of the now-vacant Michigan Central Railroad Station. According to the website, every effort to breath life into the gem has failed. Today it remains one of the country's foremost monument's to urban decline.
Lesson's for Milwaukee? At this point, following the smart decline or shrinking cities model seems to be better suited for cities where the entire region is in decline (Youngstown, etc.). The Milwaukee region, after all, is still growing on the edges. The model that Milwaukee is following is not to give up on the city but to "fill in" the city with development - Park East, the Valley, 30th Street Industrial Corridor, Pabst Brewery, etc. But what does Milwaukee do about the high cost of maintaining a crumbling infrastructure? After all, what once was a city of 741,324 in 1960, is now a city of 578,887 (as of 2005). Sure, household size has decreased which has the effect of filling up more homes, but it's still not hard to find abandoned factories, empty storefronts and vacant homes. Should Milwaukee continue to beat the drum of growth, or should we embrace our shrinking city status by instead focusing on making this the best city possible for the 578,887 that remain?
In the end, a little bit of growth AND a little bit of "right-sizing" might be required to sustain the quality of life that every city resident is entitled. Regardless of what you think of these ideas, add smart decline and shrinking cities to your urban lexicon.
Thursday, May 17, 2007
This month a campaign to increase high school graduation rates was launched by the Bill & Melinda Gates Foundation, Civic Enterprises, the National Governors Association (NGA), Time, MTV, and Education Week. A summit was held in Washington D.C. May 9 that resulted in a ten-point plan, which includes a call for comparable data from all 50 states, among other things. Several organizations released new research, publications, or initiatives in conjunction with the summit, including MTV's The Dropout Chronicles, a documentary-style series following three at-risk high school students, and Education Week's cool internet graduation rate mapping tool. The Ed Week-generated map for Milwaukee is shown at left.
As a researcher who uses graduation rate data each year, the most interesting development from the summit is this push for better and more accessible data. Currently very few states, including Wisconsin, use a longitudinal method to calculate graduation rates--to attempt to follow individual students over the course of their high school years. It seems obvious that the only true graduation rate would be one that takes into account students who move, transfer to another school, or graduate early as well as those who drop out. But gathering and maintaining the neccessary individual student data is very costly and so most states choose to estimate. The result is that we don't have a handle on the true extent of the problem; thus, the "silent epidemic" moniker.
Because of this uncertainty, many researchers have come up with various ways to calculate estimates of graduation rates. One of the most prominent has been Jay Greene of the Manhattan Institute, whose methods I critiqued in a 2004 Milwaukee Journal Sentinel op ed piece. (Dr. Greene responded emphatically the next week.) The National Governors Association (NGA) decided to enter the fray with a better solution:
Recent debates among national researchers have focused on which data sources and calculations provide the best estimates of high school graduation rates...[NGA] move[s] beyond that debate by counting actual graduates.
In 2005 the governors of all 50 states signed the NGA's Graduation Counts Compact, promising to improve their graduation data and agreeing to use a uniform formula for calculating the graduation rate. So far only two states, Colorado and Maryland, have codefied the compact's common formula, but 39 states plan to report a graduation rate calculated with the common formula by 2010. Wisconsin plans to be in full compliance with the compact by 2009, and has made the necessary changes to the rate formula and data collection in order to be so.
The Forum tracks graduation rates for school districts in southeast Wisconsin in our annual Public Schooling report. The 2002-2003 rate, under the old formula (number of graduates divided by the sum of graduates plus dropouts for that class over the four years), was 76.7% in Racine, 89.8% in Kenosha, and 60.7% in Milwaukee, for example. In 2004-2005, under the new formula, the rate was 74.7% in Racine, 91.3% in Kenosha, and 59.9% in Milwaukee. The new formula is the number of regular graduates divided by an estimate of the total cohort group measured from the beginning of high school, expressed as a percentage. This total cohort group includes regular graduates, other high school completers (i.e. GED recipients), other students who reached the age 21 in the school year, and students who dropped out during the four years.
There is not much difference in the rates as a result of moving to the new formula, because the new formula has, unfortunately, still been an estimate of the graduation rate. The number of cohort dropouts has been estimated; all students leaving school are assumed to be dropouts, when in fact, they may be transferring to a different school or moving out of state. However, starting with 2006-2007 school year data, the state will be able to report an actual cohort rate for June 2007 graduates. Districts have been required to track and verify student movement over the past four years and will provide an actual cohort dropout count, which will greatly improve the accuracy of the graduation rate.
Thus, we will soon know whether the "silent epidemic" in Wisconsin is something to shout or whisper about.
Wednesday, May 16, 2007
Readers' forums are a nice feature on the Milwaukee Journal Sentinel's website. Sarah Carr's recent series on violence in MPS is the topic of a moderated forum that includes comments from several MPS students and parents. The commenters are generally thoughtful and earnest; Sarah's reporting has generated a great deal of healthy debate on a pressing issue.
The majority of comments are aimed at parents, who are seen as not fulfilling their duties to their children. One proposed solution: terminating parental rights and creating "boarding school orphanages." Believe it or not, I've heard that one before. Other comments focus on changes to the school system itself, from more security personnel to stricter enforcement of conduct codes. Of the comments I've read, the one suggestion that I haven't heard before:
Humans are motivated by many things, and schools should take full advantage of those characteristics. These include incentives that appeal to the students and punishments that don't appeal to students. Both suspensions and expulsions are not motivating to many of the students who are from low socio-economic families that do not highly value education or have given up on schools improving their lives. . . In Special Education, students have "Individual Education Plans". Perhaps parrelle [sic] to that, every child needs an "Individual Incentive Contract".Interestingly, higher quality early childhood education hasn't come up. What would your suggestion be? Surf on over to jsonline.com and participate in the discussion.
Thursday, May 10, 2007
The Pew Charitable Trusts released results from a new poll this week and have characterized the findings as an indicator that "support for government assistance to the disadvantaged [is] up to where it stood in the late 1980s..."
The new survey asked some questions that had previously been asked in 1987 and 1994:
Three core questions regularly asked in Pew surveys since 1987 were analyzed to track attitudes toward government assistance to the disadvantaged. In addition to asking about their views on government help to the needy even if it means going deeper into debt, respondents were read these statements: "The government should guarantee every citizen enough to eat and a place to sleep"; and "It is the responsibility of the government to take care of people who can't take care of themselves." Respondents were asked if they completely agreed, mostly agreed, mostly disagreed or completely disagreed with each of the three statements after it was read.Over half of this year's respondents (54%) agreed that the government should do more to help the needy, up from 41% in 1994 and about the same as in 1984 (53%). In addition, 69% agreed that the government should guarantee food and shelter to all Americans, up from 59% in 1994 and higher than in 1987 when 62% agreed. Over two-thirds (69%) agreed that it is the responsibility of the federal government to take care of people who can't take care of themselves, a 12 percentage point increase since 1994, though still less than in 1987. Overall, the percent of respondents who agreed with all three statements increased from 29% in 1994 to 41% in 2007. While the percent who disagreed with all three statements fell by nearly half, from 24% to 13%.
The gains appeared across all demographic groups except African-Americans, who had much higher support for government assistance in the '94 survey than did other demographic groups. According to Pew:
One of the largest increases occurred among the oldest Americans. Since 1994, the proportion of those 65 and older who agreed with the three propositions increased from 16% to 38%. These shifts narrowed the gap between old and young from 21 percentage points to 12 points. Support also grew disproportionately among whites (+13 points) compared with blacks, (+6 points), though a far greater share of blacks (61%) than whites (38%) consistently agreed. Among whites, the biggest increases occurred in the South, where support for the social safety net grew by 24 percentage points, from 24% to 48%.What do these findings say about the success of welfare reform nationally, which came out of the Republican-led Congress of the 90's and was signed into law by President Bill Clinton, a Democrat? Among respondents in the bottom quartile of household income, overall support for the three statements had a 21-point increase, from 38% in 1994 to 59% today. If welfare reform is not meeting the needs of families in this lowest income group, greater support for increased government assistance is to be expected. However, support for a federal safety net also increased among the highest earning households. Favorable responses from those in the top quartile of household income for all three statements increased from 16% in 1994 to 29% in 2007. The breadth and depth of the change in attitudes across all demographic groups does seem to indicate a gap between opinion and policy.
Unfortunately, the Pew survey does not report findings by state. It would be interesting to see whether attitudes in Wisconsin, the birthplace of welfare reform, have changed in the past 13 years on this issue. What has changed in our state is the volume of people receiving assistance. In 1994 the average monthly total recipients of welfare (Aid to Families with Dependent Children, or AFDC) numbered 226,197. In December 2006 the total recipients of welfare (Temporary Assistance for Needy Families or TANF) in Wisconsin equaled 36,420. It seems unlikely that a change of that magnitude wouldn't impact public opinion in some way. Is Wisconsin more or less like the rest of the nation? Perhaps an argument could be made either way.
Tuesday, May 8, 2007
The Urban Studies Program at UW-Milwaukee is sponsoring the "
This event is sponsored by the Urban Studies Program at UW-Milwaukee and co-sponsored by the
The event is free and open to the public.The evenings events will proceed as follows:
3:30 Intro's-Dean Richard Meadows and Joseph Rodriguez
3:40 Richard Longworth
4:00 Tim Sheehy
4:20 Mayor Tom Barrett
4:40 Marc Levine
5:00 Ryan Horton
5:20 Q and A from audience
Friday, May 4, 2007
A 2002 Frontline program recently brought to my attention that investigates the brain development of teenagers confronts an issue that's been raised frequently lately regarding early childhood development: Are the first three years of life all or nothing for cognitive development?
Because of the growing awareness of the importance of early childhood development and the resulting new policies directing more public investment into early childhood education, a tension among children's advocates and educators has surfaced. If public funds for education are limited, where should the dollars go? Not enough of today's teenagers are graduating, while too many toddlers lanquish in sub-quality child care. Which is the priority?
The Frontline reporters interviewed John Bruer, President of the James S. McDonnell Foundation in St. Louis and the author of The Myth of the First Three Years: A New Understanding of Early Brain Development and Lifelong Learning. Bruer's argument is that the science of early brain development does not support the need for public investment in early childhood education at the expense of other, post-K educational investments. He further criticizes early childhood advocates of misusing brain science to lobby for child care policy. He tells Frontline:
"The early campaigns really selectively chose very dated pieces of neuroscience and knit them together in a compelling way to sell a story. And the way that those campaigns were put together was pretty much in the same way we would put together an ad campaign or a publicity campaign for any other cause. There's a place for that. However, when people claim to be telling us their policy recommendations are based on science, we should be sure that they are." Bruer's book has received considerable media attention and other researchers are making similar arguments. For instance, Dr. James Heckman, a 2000 Nobel laureate in economics and strong proponent of public investment in early childhood programs, recently wrote in Education Week (March 21) that his latest work has forced him to "rethink the conventional wisdom" that investments in early childhood interventions bring the best returns for disadvantaged and at-risk children. He now believes that "interventions with children are not so productive if they are not followed up with ongoing investments in children during their elementary and secondary school years. Instead, we need to invest early in children—and not stop."
Bruer's conclusions, although not often portrayed this way, are actually similar to Heckman's. Bruer contends that brain research shows that even though a brain may physically be developing at the fastest rate in early childhood, the learning curve during that time is no different than at any other time in a child's life. He states that the most compelling research shows that learning depends on prior knowledge: "Your prior knowledge is the best predictor of how quickly and well you will learn. You can look at word learning, for example. The more words people know, the more quickly they'll learn new ones. So this notion that rate of learning is so closely linked to the biological maturation of the brain isn't a very useful one." Indeed, "it's not a biological brain maturation issue. It's cultural experience in your environment. And we have to be very careful not to confuse the culture with the biology." Thus, while he agrees that early childhood education is important in providing the knowledge base necessary for later learning, he cautions that this is not solely because of the many new brain synapses created in the first three years.
Heckman's Ed Week essay translates this notion into policy:
"Too often, government officials design programs for children as if they lived their lives in silos, as if each stage of a child’s life were independent of the other, unconnected to what came before or what lies ahead. It’s time for policymakers now to look beyond the silos, to begin recognizing that consistent, cost-effective investment in children and youths can pay for itself. Providing young people with the resources they need to compete in today’s global economy is not just a moral imperative. It is an economic necessity, tooThe take-home lesson for policymakers threefold. 1)Be aware of the limitations of the science: high quality early childhood education is not going to be a magic bullet for producing "smart kids." The positive benefits of high quality child care are not automatic because it is not a simple biological process. 2) In addition, investments in early interventions cannot supplant investments in a child's later years if you expect the best return on your investment. 3) And, as with any other education reform, accountability is key because the devil is in the details. Jack Shonkoff, author of From Neurons to Neighborhoods, cautions Frontline regarding this last point:
"The problem is sometimes we take a good model that's been shown to work, and then we try to bring it to scale and do it to serve more children for less money, with less well training of the staff; and we get more confusing and equivocal findings. So that's the problem. The problem is not whether early intervention is a good public investment. The problem is whether we invest in high-quality services that are shown to make a difference. And as we found in our report, although the science tells us interventions can be effective when they're administered early, effective interventions are not simple. They're rarely inexpensive, and they're not always easy to implement...Thus, policymakers must take care to ensure their investments in early childhood programs are monitored for effectiveness and that wide-scale implementation is done carefully. Accountability is the key to good policy as much in early childhood education as in primary or secondary education.
Tuesday, May 1, 2007
The Forum's "Salute to Local Government" which honors cooperation and teamwork in local government throughout the seven counties* of southeastern Wisconsin is now accepting nominations. If you know of a government program that might qualify, please vist this page and submit the form. There are five categories from which to choose. The deadline for nominations is Friday, May 11.
The "Salute" breakfast will be held on Wednesday, June 20 at the Italian Community Center.
*Kenosha, Milwaukee, Ozaukee, Racine, Walworth, Washington, and Waukesha counties