Editor's Note

We might have entitled this issue of the journal "Three Big Things in Health Policy." Such verbiage lacks much literary punch, but it captures the essence of this collection of articles, commentaries, and book reviews on managed competition, community partnerships, and vulnerable populations. Varying quantities of thought or money, advocacy or criticism, and action or stalemate have been associated with these themes throughout the 1990s and into the current decade. Lesson drawing and, dare I say, even progress in health care policy making in some form are far from completed or resolved. This issue of the Journal of Health Politics, Policy and Law brings us up-to-date on the current status of each of these three domains of health policy.

We open with an investigation of private-sector engagement with managed competition. Although its roots go back to Alain Enthoven's original formulation of a consumer-choice model of health care reform in the 1970s, the term managed competition entered our lexicon about twenty years later. Shortly before the 1992 elections, the Jackson Hole Group and a number of policy makers, including then presidential candidate Bill Clinton, crafted reform approaches that adopted themes, albeit not necessarily the precise instruments, from Enthoven's model. His evolving approach was to promote competition among private qualified health plans that were organized within health insurance purchasing cooperatives as the method for orchestrating cost control, quality improvement, and expanded access in the delivery of medical services. When the national health care reform debates collapsed in September 1994, attention to this approach shifted primarily to the private sector, especially the largest companies that presumably had the incentive, as well as institutional wherewithal and employee base, necessary to pursue a version of the managed competition model. In "Managed Competition versus Industrial Purchasing of Health Care among the Fortune 500," James Maxwell and Peter Temin show that Fortune 500 firms have instead shied away from managed competition in the provision of health insurance benefits. These businesses have chosen to remain true to "industrial purchasing" methods they have traditionally employed in other domains. The implications of this study and its results are considered in commentaries by two leading economic analysts of health care financing and organization, Alain Enthoven, the "father" of managed competition, and Henry Aaron, a frequent and well-recognized participant in health policy deliberations.

Just as Enthoven and other proponents of managed competition have sought to transform the core organization of American health care financing and organization, others have pursued equally dramatic changes in the understanding, organization, and delivery of health care at the level of the local community. In our August 1997 issue, Richard J. Bogue et al. introduced JHPPL readers to the Community Care Network (CCN) approach, which was launched in 1994 by the Hospital Research and Educational Trust (HRET), endorsed by the American Hospital Association, and financially supported primarily by the W. K. Kellogg Foundation. With leadership from local hospitals, community partnerships were to be formed that bring together public and private-sector participants representing both conventional medical care providers and other non-health-care-oriented institutions, such as schools, with a stake and an interest in enhancing the health of the overall community, controlling health care costs, and improving the allocation of health-associated resources. Has the experience to date offered encouragement about the prospects of both this strategy and the particular approach nurtured by HRET? About seven years into building this demonstration program, in "Evaluating Partnerships for Community Health Improvements: Tracking the Footprints," a team lead by Stephen M. Shortell assesses the midstream performance of twenty-five CCN partnerships. Arguing that a shared vision among participants and well-developed management capabilities are essential to the long-term successful performance of these partnerships, the authors report on the sources of variation across the sites. Both the overall CCN strategy and the approach taken in this evaluation raise questions about how to achieve improvements in community level health care. Two commentators help us to...