During the 1990s, statutory changes first limited and then eliminated drug abuse and alcoholism as a basis for eligibility for the receipt of benefits under the Social Security Disability Insurance and Supplemental Security Income programs. Such provisions are not unusual. The laws and regulations that establish the framework for governmental programs commonly include provisions aimed at minimizing or preventing secondary outcomes viewed as undesirable by some policymakers. It is hardly surprising that policymakers might worry that the availability of disability benefits might foster substance abuse. But did it?

In “Effects of Alcohol Consumption on Disability among the Near Elderly: A Longitudinal Analysis,” Jan Ostermann and Frank Sloan use data from the national Health and Retirement Study to assess the relationships among alcohol consumption, disability, and the receipt of income from the SSDI and SSI programs. Data were collected in four waves in this survey during the 1990s, including before and after the legislative changes were made in the federal disability programs. Ostermann and Sloan’s analysis raises doubts about both the premise and the effectiveness of these changes insofar as alcohol abuse is concerned. Heavy drinkers were not more likely than light or moderate drinkers to receive public income support before the restrictions on benefits were introduced, and the proportion of heavy drinkers among program recipients did not decline even after the most stringent restrictions were made in 1996.

In the second article in this issue, “The Effect of State Regulations on Motor Vehicle Fatalities for Younger and Older Drivers,” David Grabowski and Michael Morrisey critically review the published studies on the effectiveness of various regulatory approaches for reducing fatalities among two high-risk groups of drivers. These approaches include various types of restrictions on licenses for both young and older drivers, as well as alcohol regulation, speed limits, and seat belt laws. Grabowski and Morrisey find persuasive evidence that certain measures are effective (e.g., enforced seat belt laws reduce motor vehicle fatalities among younger drivers) but that studies on some measures leave important questions about effectiveness unanswered. For example, there is good evidence that limiting the exposure of younger drivers to certain risk factors (e.g., nighttime driving) reduces fatalities in that age category. What is not known, however, is whether the fatalities associated with those very risk factors might still be taking place—but at a later age (e.g., whenever nighttime driving begins). But perhaps the most striking finding from Grabowski and Morrisey’s review is the dearth of studies on the effectiveness of measures to reduce fatalities among elderly drivers. This is important because of the growing size of this population, the burdens imposed by license restrictions, and the fact that fatalities per 100,000 older drivers have been increasing for the past quarter century.

In “Health Promotion and the First Amendment: Government Control of the Informational Environment,” Lawrence Gostin and Gail Javitt consider the applicability of the U.S. Constitution to American health policy, a topic only occasionally addressed in the health policy literature. Gostin and Javitt are concerned with the government’s power—and limits thereon—to exert control over the public’s receipt of information that is pertinent to health. They analyze three means by which government might do this: through restrictions on commercial speech, through requirements that might be attached to commercial speech (e.g., warning labels), and through health-related messages by the government itself. As Gostin and Javitt note, the First Amendment protects private citizens from governmental interference with expression, but it has no specific application when government is the speaker. They report that there is very little jurisprudence or scholarship on the permissible boundaries of government speech on matters of health. Drawing on the law that applies to commercial speech, Gostin and Javitt propose some legal and ethical principles that should apply when the government is the source of information.

“Does the Chronic Care Model Serve Also as a Template for Improving Prevention?” by Russell Glasgow, Tracy Orleans, Edward Wagner, Susan Curry, and Leif Solberg, extends work previously published in these pages (see Wagner et al., MQ 74[4]:511–44). The Chronic Care Model of disease management is being used in settings such as Group Health Cooperative of Puget Sound. The model, which involves organizational design, clinical and decision support systems, self-management support, and linkages to community resources, is designed to assure that patients receive effective interventions and that the needs of patients and their families for information, behavioral support, and continuity are met. This model addresses some widely recognized deficiencies of the U.S. health care system, which is organized around the treatment of acute conditions and symptoms. In this article, Glasgow and colleagues describe how the Chronic Care Model can apply to primary care. They analyze the applicability of the six components of the model to the prevention as well as to the management of chronic disease, illustrating their analysis with examples. They also argue that the model has utility across different types of health care organizations.

In “Trust in Physicians and Medical Institutions: What Is It, Can It Be Measured, and Does It Matter?” Mark Hall, Elizabeth Dugan, Beiyao Zheng, and Aneil Mishra review the many articles about trust that have appeared in recent years, and they present a conceptual framework for organizing thought on this topic. They ask whether there is a shared understanding in these articles about the meaning of trust, and they summarize what is known about the factors that affect trust, how trust relates to kindred concepts (e.g., satisfaction), and what difference trust makes. They note that many “casual assumptions” about the causes and effects of trust do not bear up under empirical scrutiny. Despite all of the concerns about health system changes that undermine trust, Hall and his colleagues report that most studies find that patients have quite a high level of trust in their physicians. This trust, they argue, emanates more from the psychological realities of the care-seeking situation than from any characteristics of physicians or organizations. This, they conclude, makes it essential that all levels of the health care system be trustworthy.

Bradford H. Gray
Editor, The Milbank Quarterly

Author(s): Bradford H. Gray

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Volume 79, Issue 4 (pages 483–485)
DOI: 10.1111/1468-0009.00183-i9
Published in 2001