Journal of Health Politics Policy & Law

Journal of Health Politics, Policy and Law
Volume 28, Number 2-3, April 2003
Special Conference Issue: Who shall Lead?


Contents

Articles

Part 1-The Public Sector: A New Federalism?

    Tuohy, Carolyn J., 1945-
  • Agency, Contract, and Governance: Shifting Shapes of Accountability in the Health Care Arena
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    Subject Headings:
    • Medical care -- United States -- Evaluation.
    Abstract:
      Current ideas about the role of the state include an enthusiasm for mechanisms of "indirect" or "third-party" governance. The health care arena, in which models of indirect governance have a long history, is an important test bed for these ideas. Classically, the arena was marked by trust-based, principal-agent relationships established to overcome information gaps. Over time (and to different degrees across nations), emphasis shifted to contractual relationships assuming relatively well-informed actors and then to performance monitoring and information sharing within complex and loosely coupled networks. In this latest stage, there is a risk that some important features of democratic leadership, and of decision making in the health care arena, will be eclipsed. Accountability mechanisms must clearly locate responsibility for actions and must allow for the exercise of professional judgment.
    White, Joseph.
  • Three Meanings of Capacity; Or, Why the Federal Government Is Most Likely to Lead on Insurance Access Issues
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    Subject Headings:
    • Medical policy -- United States.
    • Insurance, Health -- United States.
    • Managed care plans (Medical care) -- United States.
    Abstract:
      This essay considers on what health policy issues the federal government is best able to lead. Positive leadership requires knowledge, power, and will. The federal government has different supplies of each for different aspects of quality of, cost of, and access to health care. Here I review technical capacity to attain desired ends, define the institutional strengths and weaknesses of the federal government, and outline current dynamics of the national political process. This analysis suggests both prospects for and some characteristics of successful policy. The federal government is more likely to lead on insurance than on other health policy issues because its supply of relevant knowledge and power is relatively high on insurance issues and the political barriers are lower than conventional wisdom suggests. But that leadership could take the form of either the expanding or contracting of access to insurance.
    Sparer, Michael S.
  • Leading the Health Policy Orchestra: The Need for an Intergovernmental Partnership
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    Subject Headings:
    • Medical policy -- United States -- States.
    • Intergovernmental cooperation -- United States -- States.
    Abstract:
      The past decade provides a useful window through which to examine whether states are likely to provide health care leadership. During this era, states were given increased discretion to set health care policy, they had the financial resources to encourage innovation, and their administrative capacity was at its strongest ever. Despite the favorable conditions, however, states were reluctant to spend their own funds on programs for the uninsured, their efforts to make private insurance more affordable for the small business community were disappointing, and their efforts to regulate the managed care industry fell short. At the same time, though, the most promising innovations over the past decade were in programs financed primarily with federal dollars, administered primarily by state officials, and advanced by an intergovernmental partnership in which administrators at different levels of government prod each other to try and do more. This sort of intergovernmental partnership provides the best model for innovative health policy leadership.
    Morone, James A., 1951-
    Kilbreth, Elizabeth H.
  • Power to the People? Restoring Citizen Participation
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    Subject Headings:
    • Medical policy -- United States -- Citizen participation.
    • Managed care plans (Medical care) -- United States.
    Abstract:
      This article investigates a lost ideal—citizen participation in health policy. We begin by mapping the different types of participation. We then suggest what direct citizen action has achieved in the past, why it ought to be restored today, and how we might go about reviving it. A changing social environment—marked by globalization, immigration, a culture war, and managed care—could be addressed by robust, local, democratic health reforms. Finally, we contrast the top-down health sector with education and crime policies that take communities far more seriously.

Part 2-The Private Sector: A New Industry?

    Laugesen, Miriam.
    Rice, Thomas.
  • Is the Doctor In? The Evolving Role of Organized Medicine in Health Policy
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    Subject Headings:
    • Medical policy -- United States.
    • Physicians -- United States.
    Abstract:
      Until recently, physicians were viewed as the dominant player in health policy. Now, however, they compete with many other effective interest groups. This article analyzes this changing role, and specifically how organized medicine has changed its approach to influencing health policy. The essay begins with a review of the reasons for the growth and subsequent decline of physicians' influence. This is followed by a case study of physician payment reform under Medicare, which illustrates the ways in which organized medicine chooses when and when not to cooperate with government. The article concludes with a discussion of where physicians are likely to continue to be influential in future health policy reform. Three such areas are noted: payment policy, quality and clinical innovation, and medical education and training.
    Martin, Cathie J.
  • Employers: Passive Purchasers or Provocateurs?
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    Subject Headings:
    • Medical policy -- Business community participation -- United States.
    • Insurance, Health -- United States.
    • Medical economics -- United States.
    Abstract:
      This article addresses the potential role of business leadership in diverse efforts to reform health care financing: exploring managers efforts to alter health care markets in their role as large purchasers of health insurance, their potential contributions to future national policy proposals, and their involvement with community-level activities to control local health costs and quality. I argue that managers' leadership in market restructuring and community health initiatives will be difficult to reproduce in the realm of major national health policy initiatives due to constraints related to ideas, interests, and organization.
    Robinson, James C. (James Claude), 1953-
  • The Politics of Managed Competition: Public Abuse of the Private Interest
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    Subject Headings:
    • Medical economics -- Social aspects -- United States.
    • Insurance, Health -- Social aspects -- United States.
    • Medical policy -- United States.
    Abstract:
      The doctrine of managed competition in health care sought to achieve the social goals of access and efficiency using market incentives and consumer choice rather than governmental regulation and public administration. In retrospect, it demanded too much from both the public and the private sectors. Rather than develop choice-supporting rules and institutions, the public sector has promoted process regulation and benefit mandates. The private health insurance sector has pursued short-term profitability rather than cooperate in the development of fair competition and informed consumer choice. Purchasers have subsidized inefficient insurance designs in order to exploit tax and regulatory loopholes and to retain an image of corporate paternalism. America's health care system suffers from the public abuse of private interests and the private abuse of the public interest.
    Reeher, Grant.
  • Reform and Remembrance: The Place of the Private Sector in the Future of Health Care Policy
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    Subject Headings:
    • Medical policy -- United States.
    • Health maintenance organizations -- United States.
    • Managed care plans (Medical care) -- United States.
    Abstract:
      Although the nation failed during the past decade to enact large-scale, structural change in government health policy, it has seen health care in the private sector remodeled dramatically during the same period. In this article I argue that a new round of equally significant changes is quite possible, this time at the hands of the national government. More specifically, I argue that for a variety of reasons, both enduring and more recently born, support for the private sector and the market in health care is relatively weak; that given likely trends in costs, demographics, and inequalities, it is likely to get even weaker; and that in the potential coming crisis of the health care system, there will be a real opportunity for seizing the agenda and winning policy battles on the part of would-be reformers pushing large-scale, public sector-oriented changes that go well beyond the recent reform efforts directed at managed care and HMOs.

Part 3-New Sources of Change?

    Sage, William M.
  • Unfinished Business: How Litigation Relates to Health Care Regulation
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    Subject Headings:
    • Medical policy -- United States.
    • Medical laws and legislation -- United States.
    Abstract:
      "Regulation by litigation" is a recently recognized trend in American legal governance that develops differently in each economic sector it affects. In health care, widespread litigation can be viewed as the product of three partial transformations: incomplete industrialization, incomplete consumerism, and incomplete social solidarity. One can argue that the public turns to the courts because other actors who might exercise judgment and authority to resolve problems appear unreliable. Because litigation has several features at odds with sound health policy—including its cost, its hindsight bias, and its adversarial character—it may be necessary to develop new discretionary institutions to address specific questions that regulators cannot or will not answer.
    Mechanic, David, 1936-
  • Who Shall Lead: Is There a Future for Population Health?
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    Subject Headings:
    • Public health -- United States.
    • Medical policy -- United States.
    Abstract:
      Despite renewed interest in population health concerns, elevation of this field in policy considerations faces many challenges. At present there is much concern about disparities and meeting improved population health objectives, but interest waxes and wanes with scientific developments and especially with dominant political alignments and ideologies. If the field of population health is to have sustained policy influence, it requires a persistent constituency, a strong organizational base both within and outside of government, and academic respectability. Population health faces many issues in seeking to become legitimized as both a unique field of study and as a significant force in public policy. Among these are a clear definition of the boundaries of the field, a continuing flow of resources for development, and attractive career structures for new recruits and future leaders.
    Nathanson, Constance A.
  • The Skeptic's Guide to a Movement for Universal Health Insurance
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    Subject Headings:
    • Insurance, Health -- United States.
    • Medical policy -- United States.
    Abstract:
      The social movement has become institutionalized as a form of political action. The aim of this article is to evaluate the possibilities presented by this form as a strategy to bring about universal health insurance in the United States. I draw on the work of social movement theorists, on the substantial body of empirical research on health-related social movements, and on relevant comparative work from Canada to develop a template for this evaluation. Using that template I compare the failed campaign for President Bill Clinton's health insurance plan with a recent, more successful campaign in the state of New York. I conclude that the keys to success are, first, a broad-based coalition that combines an ideologically and/or grievance-motivated grass roots with financially and politically well-endowed mainstream organizations; second, a "master frame" that resonates with the American people; and, third, a political window of opportunity. The prospects for such a conjunction are not hopeless, but they are not high.
    Light, Donald, 1942-
    Castellblanch, Ramón.
    Arredondo, Pablo.
    Socolar, Deborah.
  • No Exit and the Organization of Voice in Biotechnology and Pharmaceuticals
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    Subject Headings:
    • Organizational sociology.
    • Biotechnology industries -- United States.
    • Pharmaceutical industry -- United States.
    • Medical policy -- United States.
    Abstract:
      Although leadership is typically seen as coming from the leaders of governments and major institutions, a strong case can be made that concerned citizens first articulate important issues and policies that official leaders then pick up and promote. In a market-based society dominated by large corporations, Hirschman's framework of exit, voice, and loyalty can be used to relate consumer and grassroots movements to markets, when participants believe there is no exit and loyalty (or acquiescence) is not an option. While "voice" is usually applied to the individual or consumer level, this article develops the concept of organized voice and illustrates how it has exhibited leadership in the controversial relations between the biotech and pharmaceutical industries and society as a whole. The essay concludes by urging more research on organized voice as a source of leadership and by outlining some important dimensions for researchers to consider.

Part 4-Commentaries

    Brown, Lawrence D. (Lawrence David), 1947-
  • Shadow Governance: The Political Construction of Health Policy Leadership
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    Subject Headings:
    • Health maintenance organizations -- United States.
    • Medical policy -- United States.

Books

    Mariner, Wendy K.
  • Public Health and Law: Past and Future Visions
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    Subject Headings:
    • Gostin, Larry O. (Larry Ogalthorpe) Public health law: power, duty, restraint.
    • Public health laws -- United States.
    Sakaguchi, Ann Mariko.
  • Health Equities Worldwide
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    Subject Headings:
    • Evans, Timothy (Timothy G.), ed. Challenging inequities in health: from ethics to action.
    • Public health -- Moral and ethical aspects -- Cross-cultural studies -- Congresses.
    Hall, Mark A., 1955-
  • Holding Health Care Accountable: Law and the New Medical Marketplace (review)
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    Subject Headings:
    • Morreim, E. Haavi. Holding health care accountable: law and the new medical marketplace.
    • Managed care plans (Medical care) -- Law and legislation -- United States.
    Sparer, Michael, S.
  • The New Politics of State Health Policy (review)
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    Subject Headings:
    • Hackey, Robert B., ed. New politics of state health policy.
    • Rochefort, David A., ed.
    • Medical policy -- United States -- States.



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