bluuebunny/crossref_metadata_2025 huggingface dataset:
Ambiguous Evidence and Institutional Interpretation: An Alternative View of Electric and Magnetic Fields
Authors: Linder Stephen H.
Published: January 2008

There is a notable lack of scientific consensus on whether electric and magnetic fields (EMF) constitute a health risk in need of systematic control. Even those who see EMF as a public problem, share few assumptions about the type of problem it represents, whether serious risks to health are involved, or about the collective action it warrants. In the absence of conclusive scientific evidence, the interpretations of various social and political institutions have moved into the foreground, each bringing a different perspective to the issue and a unique way of accommodating the ambiguity surrounding the question of health effects. The result is a confusing mixture of warnings and reassurances, of calls for more study, or for immediate action, that distinguishes the EMF issue from other, better-defined environmental risks. While much of the discussion of EMF has focused on the synthesis and assessment of experimental and epidemiologic research on health effects, this paper explores the diversity of institutional interpretations to shed some light on the social and political responses to the issue and how these might shape its future in public policy. The paper concentrates on the selected norms and practices of three institutions, centrally involved yet differing in their interpretations: the scientific community, the legal system, and public bureaucracy. The disparities that form among the interpretations of institutions faced with ambiguous evidence and ill-formed problem definitions can lead to tensions and a search for alternative means of resolving contested meanings.
Knowing and Acting in Medical Practice: The Epistemological Politics of Outcomes Research
Authors: Tanenbaum Sandra J.
Published: January 2008

Recent health care policymaking favors outcomes research as a response to the putative ineffectiveness, as well as the undeniable expense, of American medicine. This small-scale ethnographic study conducted in a department of internal medicine evaluates claims that probabilistic knowledge will improve clinical practice. It finds that physicians are primarily determinists and that although they reason probabilistically in some instances, they rely on personal experience over research data at these times; that doctors view outcomes research as useful but not definitive and in no way immune to the social influences on medical knowledge generally; and that their mix of determinism and probabilism is well suited to the nature of medical work. The recent ascendancy of outcomes research is as much political as scientific, empowering the research community relative to practicing physicians, lending medical legitimacy to payer-promulgated practice guidelines, and creating additional clinical work around a false standard of medical certainty.
The $147,000 Misunderstanding: Repercussions of Overestimating the Cost of AIDS
Authors: Green Jesse , Oppenheimer Gerald M. , Wintfeld Neil
Published: January 2008

The increasing incidence of AIDS in the 1980s prompted inquiry into the resources required to meet projected needs. In the first economic study to appear on the illness, the Centers for Disease Control (CDC) estimated that the costs of inpatient care were $147,000 per AIDS patient, heightening concern that the health care system would be overwhelmed by the epidemic. However, every study published subsequently has produced much lower cost estimates. As a result, many have concluded that treatment costs declined due to improved delivery of AIDS care. We offer an alternative interpretation, based on evidence demonstrating that the CDC's methods and assumptions yielded a figure about three times too high. The CDC's erroneous estimate had significant policy repercussions. Using the $147,000 figure, the health insurance industry lobbied successfully for the right to screen applicants for HIV. Next, when a study of San Francisco AIDS patients found local hospital costs per case to be $27, 571, many concluded that billions of dollars could be saved if the “San Francisco model” of care (emphasizing home and community-based services and case management) were universalized. Since then, most programs for AIDS services have provided funds for community care. While such programs improve access to vital services, they are unlikely to guarantee “better care for less money.” A more informed understanding of the cost of AIDS should lead to programs that also strengthen inpatient care.
How Will We Use Clinical Guidelines? The Experience of Medicare Carriers
Authors: Grogan Colleen M. , Feldman Roger D. , Nyman John A. , Shapiro Janet
Published: January 2008

While support for the development of clinical guidelines is widespread, there is little agreement about how they should be used. Because cost control is the force behind the medical effectiveness movement, the payers' preference, to link clinical guidelines to reimbursement, will likely prevail. We examine the utilization review programs of Medicare Part B carriers and the carriers' attempts to use clinical guidelines to determine medical necessity for the purpose of payment. We find that because the utilization review programs are driven by concerns about cost control, the carriers' actual review process relies on aggregate utilization and spending targets that have little to do with clinical guidelines. The carriers' medical review rhetoric using the terms medically unnecessary and fraud and abuse as synonymsalso highlights their focus on cost control and the lack of concern about why services are used inappropriately.
Concrete Fictions and Hegemonic Methodologies: Doing Policy Research in Government
Authors: McAllister William
Published: January 2008

Faced with having to justify programs to offices of management and budget, government agencies generate numbers which describe expected program impacts. But the assumptions or data on which these numbers are based are frequently suspect, as is the utility of relying on counts and modeling techniques for evaluating the achievement of program aims. The result is that agencies often create “concrete fictions,” hard numbers with feet of (soft) clay. Offices of management and budget are able to make their methodology “hegemonic” because agencies usually have to secure their approval to get funding. But imposing this methodology encourages agencies to use research staffs more to defend against the budget office than to help create effective programs, creates differences between the expectations of government and the public, and fosters the overrepresentation of particular interests.
A Gender Analysis of Policy Formation: The Case of Fetal Abuse
Authors: Schroedel Jean Reith , Peretz Paul
Published: January 2008

In this paper we argue the value to policy research of taking a feminist perspective on policy issues. We show the development of fetal abuse as a policy issue and how the often unconscious patriarchal stance taken by those participating in the debate has led to fetal abuse being defined as an issue that arises from the negligence of women, when an equally good case can be made for male fetal abuse. We then show how this definition of the problem followed from the patriarchal belief systems of those who framed the issue.
Understanding the Choices in Health Care Reform
Authors:   The Health Care Study Group
Published: January 2008

This commentary is the joint product of a group of concerned scholars, many of them long associated with this journal. It assesses the debate over health care reform with the goal of minimizing the many myths and misunderstandings that exist. We address eight issues most likely to engender confusion: (1) the question whether cost control and universal coverage are contradictory goals, (2) the definition of universal coverage, (3) sources of bureaucracy in a reformed health care system, (4) the meanings of “competition” and “regulation,” (5) the difference between short- and long-term measures to control costs, (6) subsidization of universal health care, (7) the role of medical care professionals in decision making about the delivery of services, and (8) the meaning of “choice” for patients and caregivers.
Access to Long-Term Care: Race as a Barrier
Authors: Falcone David , Broyles Robert
Published: January 2008

Race continues to impede access to health services, for acute as well as long-term care. Whites, for example, use disproportionately more days of nursing home care than do nonwhites, not simply because they are more likely to be private payers and, therefore, are preferred over nonwhites: the difference in utilization persists even among those whose nursing home stays are covered by Medicare. Using data from a study of patients awaiting alternative placement in North Carolina acute care general hospitals in 1991, this article examines racial differences in discharge delay, that is, in the time between when a patient is medically ready for discharge to another form of care and when he or she actually is discharged. Logistic regression and ordinary least squares are used heuristically to identify patient characteristics associated with delay, and two-way analyses of variance are used to document the independent effect of race. The results indicate that race has substantial independent explanatory power. This finding is reinforced by the analyses of variance with controls for the patient's payment source for long-term care, chronic condition or special care requirements, demographic attributes, family cooperativeness, whether the patient had a behavior problem that impeded the discharge planning process, and whether there was a financial problem in arranging for the patient's discharge. The inescapable conclusion is that nursing homes discriminate on the basis of race in admitting patients. This practice is patently objectionable; it also is costly to hospitals, thus to society, since hospitals bear the direct costs of delayed discharges and hospitals do not keep costs to themselves. While research is needed to determine whether the North Carolina findings are replicable in other states, past research suggests that the problem is not confined to this state.
Nursing Studies Laid End to End Form a Circle
Authors: Friss Lois
Published: January 2008

As early as 1915, leaders in the nursing profession were concerned with the “image problem of nurses,” which they saw as needing improvement. Since then, countless studies, reports, and commissions have attempted to explain and solve perceived shortages of registered nurses, which have occurred regularly after brief periods of quiescence or oversupply. Usually, their recommendations have hinged on nurses changing their image. In fact, few of these studies have dealt with the real issues of nursing work, which are a narrow pay range, little extra pay for working on undesirable shifts, disincentives for full-time work, pay unrelated to education, and education unconnected to job level. The multiple studies and commissions do nothing more than recycle data and in the process obscure fundamental problems. Educational funding has been no more successful. Their ineffectiveness suggests the need for less “image enhancement” and more support from physicians and employers to bring about systemic reform. This includes licensing nurses according to their education, assigning them according to their competencies and education, and paying accordingly. These measures, and only these, will eventually curtail the cycles of nursing “shortages.”
Notes from the Insurance Underground: How the Chronically III Cope
Authors: Kinney Eleanor D. , Steinmetz Suzanne K.
Published: January 2008

Abstract This report from the field is an account of the experience of individuals with multiple sclerosis (MS) in Indiana in getting and keeping private health insurance. The report presents the findings of a telephone survey of individuals with MS in Indiana. While survey respondents were generally able to obtain health insurance through the Medicare program or employer-based private health insurance plans, many experienced formidable barriers to adequate and affordable health insurance, such as preexisting exclusions, cancellations, high premiums, and coinsurance. Respondents adopted a variety of strategies to keep private health insurance, including selectivity in submitting claims, which worked to reduce their health insurance coverage. Our findings raise two crucial questions: (1) to what extent are the chronically ill forced to take extraordinary measures to get and keep health insurance? and (2) to what extent do insurer practices in pricing insurance and determining coverage of benefits actually make health insurance even more inadequate and unaffordable for the chronically ill? These two questions are critical in understanding the full dimensions of the health insurance crisis in the United States today.
Doctors and Public Authorities: The Trend toward Collaboration
Authors: Glaser William A.
Published: January 2008

Insuring a population and managing its money require a comprehensive health care financing system. Many issues must be resolved, particularly the roles of the medical profession and its relationship with organizations of laymen in insurance carriers and in government. The spread of society-wide, third-party reimbursement produced conflicts with doctors over admission to practice, work rules, and pay in all countries. Eventually new arrangements were made to settle conflicts of interest and to ensure the harmonious operation of health care services. Policymakers and financial managers came to realize that the medical profession as a whole must be motivated to ensure the success of the system. Recently countries with statutory health insurance and direct public financing created new systems for negotiation and for joint decision making. Even some governments now agree to collaborate with doctors as virtual peers rather than to dictate rules and finance. The only exception is the United States, which will continue to have periodic conflicts until it crafts a joint decision-making system. The evidence comes from the author's first-hand field research over thirty years in the principal developed countries in Europe and North America. He interviewed informants, collected reports, and observed events for these topics primarily in Germany, France, the Netherlands, Great Britain, Canada, and the United States.
Scientism and Economism in the Regulation of Health Care
Authors: Frankford David M.
Published: January 2008

As health care costs continue their apparently relentless rise, it seems to be universally perceived that the United States and western Europe are gripped by a cost crisis. To resolve the apparent crisis, U.S. and western European governments and third-party payers are turning increasingly to a new positivist discipline, called health services research, for which neoclassical health economics is the dominant discourse. However this discipline may actually reinforce the strength of biomedical positivism and the concomitant technological imperative. Like biomedicine, health services research is technologically driven, dependent on “advances” that generate more comprehensive and therefore more “accurate” data. Accordingly, just as biomedicine causes health care workers and patients to depend on technologies for diagnosis and treatment, health services research instills in the body politic dependence on technocratically conceived solutions for political problems. Moreover, because biomedicine and health services research share positivist epistemic and methodological premises, both objectify the subjects they study, abstract those subjects from context, and thereby ignore the cultural dimensions of the problems at hand. Rather than inculcate an ethic and practice in which medicine focuses on the meaning of illness for a life, a cultural phenomenon, this form of positivism strengthens the tendency to reject meaning in favor of the causes and course of disease and the abstracted probability of its occurrence. Accordingly health services research and the forms of regulation with which it is allied threaten to overwhelm the medical humanities movement. Furthermore this scientism precludes the institutionalization of political forums in which we can deliberate on the meaning of medicine, health, and death in our lives.
State Responses to the Medicaid Spending Crisis: 1988 to 1992
Authors: Coughlin Teresa A. , Ku Leighton , Holahan John , Heslam David , Winterbottom Colin
Published: January 2008

In recent years the growth of Medicaid spending has been a serious state budgetary problem. Between 1988 and 1992, state Medicaid expenditures increased at an average annual rate of 21 percent. Even when accounting for funds from special revenue programs, such as provider tax and donation programs, state Medicaid spending increased by 16 percent each year between 1988 and 1992, which is far higher than in previous years. This rapid expenditure growth occurred when states were having economic slowdowns and facing fiscal pressures in many other areas. Using a case study approach, we investigated the strategies used by nine states to address the recent surge in Medicaid spending. Despite fiscal pressures, the states generally avoided large-scale cutbacks in Medicaid. Instead they implemented a wide range of budgetary actions to reduce the effect of Medicaid growth, including incremental program cutbacks, constraining other budgetary sectors, shifting program costs to the federal government, and raising state taxes.
Integration of Community-Based Services for the Severely Mentally III and the Structure of Public Funding: A Comparison of Four Systems
Authors: Provan Keith G. , Milward H. Brinton
Published: January 2008

Despite strong interest by health care services researchers in studying community-based service delivery to persons with severe mental illness, few understand the relationship between the structure of public funding and differences in how mental health care delivery systems are organized. In particular, the structure of public funding may have a substantial effect on the nature and extent of integration among the various service providers that comprise a community's delivery network. Such an understanding is critical if mental health policymakers are to use their influence on funding to guide the structure of service delivery. To investigate this issue, we compared community mental health care systems in four U.S. cities. We found that services will be integrated regardless of the structure of public funding but that the structure of integration among providers will be affected. Spccilically strong fiscal control by the state is conducive to delivery systems that are integrated through the core mental health care agency in a community, whereas weak fiscal control is more likely to result in decentralized integration among system providers.
Federal Antitrust Merger Enforcement Standards: A Good Fit for the Hospital Industry?
Authors: Bazzoli Gloria J. , Marx David , Arnould Richard J. , Manheim Larry M.
Published: January 2008

We examine the implications of the 1992 Horizontal Merger Guidelines for the hospital industry and subsequent policy statements that were developed for health care providers. Application of antitrust policy to hospitals has raised several concerns, mainly because many communities have few hospitals and economic forces in the industry are accelerating interest in intramarket mergers and provider network development. We address several issues, including the standing of hospitals relative to the market concentration thresholds of the merger guidelines, market concentration compared among challenged and unchallenged mergers of the 1980s, findings of previous research about the relationship between market concentration and competition in hospital markets, and differences in characteristics other than market concentration that are relevant to the merger guidelines among challenged and unchallenged mergers. We found that (1) the specific standards articulated in the merger guidelines do not provide good predictability of when a hospital merger challenge would occur, and (2) comparisons of challenged and unchallenged mergers in similarly structured markets suggest that enforcement actions may deviate in practice from the enforcement principles of the merger guidelines. We consider several options for refining antitrust enforcement policy. Refinement of enforcement policies is important given the industry restructuring that is likely through health care reform.
Balance Billing Under Medicare: Protecting Beneficiaries and Preserving Physician Participation
Authors: Colby David C. , Rice Thomas , Bernstein Jill , Nelson Lyle
Published: January 2008

Medicare's experience with balance billing provides valuable lessons for policy making for national or state health care reform. Medicare developed several policies to encourage physicians to become participating providers who accept Medicare-allowed charges as payment in full. Only nonparticipating physicians are permitted to bill for additional amounts beyond that paid by Medicare, and there are limits on the amount of balance billing per claim. As shown by the analysis of claims presented in this article, Medicare has successfully provided financial protection to beneficiaries. In 1986, more than 60 percent of expenditures for physician services were on assigned claims for which there could be no balance billing; by 1990, 80 percent of expenditures were on assigned claims. Balance billing decreased by about 30 percent during the same period. Although these policies have been successful in reducing total expenditures for balance billing, they may not provide financial protection to the most economically vulnerable beneficiaries. Using survey and claims data, we found that the poor have lower balance billing expenditures for services provided by primary care physicians, but that there is no relationship between poverty status and balance billing expenditures for services of nonprimary care physicians. In addition, most low-income beneficiaries are liable for balance bills. Under health care reform, adoption of Medicare's incentive-based approach with mandatory assignment for the poor would allow for some choice based on price and would provide financial protection for all consumers.
Continuing Care Retirement Communities: Prospects for Reducing Institutional Long-Term Care
Authors: Sloan Frank A. , Shayne May W. , Conover Christopher J.
Published: January 2008

Continuing care retirement communities (CCRCs) combine housing and long-term care (LTC) services, including personal and nursing home care. The amount of LTC that is prepaid varies by type of CCRC, with one-third offering extensive (fully prepaid) contracts for LTC. CCRCs are a potentially promising model for LTC delivery because they offer a full continuum of services and can substitute less expensive supportive care for institutional care. Using data on CCRCs, we tested one central hypothesis: Provision of supportive services, particularly when combined with capitation, reduces use of nursing home care. To test this hypothesis, we studied the effect of various contract types for LTC services offered by CCRCs and provision of support services on utilization of nursing home and personal care units. Compared with other types of CCRCs, those offering completely prepaid LTC coverage reduced use of nursing home care by 13 percent and personal care by 5 percent. CCRCs with prepaid LTC coverage did not use more stringent health screening at entry, so “cream-skimming” does not appear to explain this result. However, affordability is an important issue: CCRC residents with extensive contracts were wealthier than were other CCRC residents.
Malpractice Reform in the 1990s: Past Disappointments, Future Success?
Authors: Kinney Eleanor D.
Published: January 2008

State governments, the federal government, interest groups, and researchers have proposed various approaches to reform the malpractice system. Malpractice reforms fall into two generations. First-generation reforms are those adopted by states beginning in the 1970s chiefly to reduce claim frequency and severity and thereby improve the malpractice system primarily from the perspective of providers and insurers. Scholars and interested constituencies developed second-generation reforms, such as use of medical practice guidelines to set the standard of care, various no-fault approaches, enterprise liability, mandated alternative dispute resolution, and scheduling damages, to streamline the adjudication and compensation system from the perspective of claimants and providers. Research indicates that first-generation reforms have not been very effective in achieving the compensation and deterrence goals of tort, whereas second-generation reforms hold greater promise of doing so. This analysis of state and federal legislation indicates that states, and more recently Congress, have been reluctant to adopt second-generation reforms but continue to promote and/ or adopt first-generation reforms. The strength of the provider lobby, concerns of health care reformers about the relationship between defensive medicine and health system costs, and lack of an organized consumer force for second-generation malpractice reform are important explanations of why the states and Congress have not embraced second-generation reforms. Furthermore, federal and state legislative interest in second-generation reforms, although never high, is waning in the current health care reform debate.
Health Care Reform in the Netherlands: Balancing Corporatism, Etatism, and Market Mechanisms
Authors: Schut Frederik T.
Published: January 2008

The transformation of the Dutch health care system and the impetus behind the market-oriented health care reforms implemented since 1989 are examined. During the postwar period, the gradual transformation of the Dutch health care system was interrupted twice by attempts to introduce radical reforms: the 1974 comprehensive health plan and the 1987 pro-competitive national health insurance program. The market-oriented reform involves a fundamental change of the incentive structure for insurers and providers. The objective is to interest both parties in containing costs and improving efficiency while preserving universal access through central redistributive financing. In the Dutch political context, radical reform proposals can be introduced only by a prolonged series of incremental changes, which offer the corporatist organizations of providers and insurers ample opportunity to dismantle the original reform design. The 1974 comprehensive health plan failed largely because of this corporatist trap. The 1987 market-oriented reform program faced the same risks, although it appeared to offer an ingenious political compromise. Private health insurers were particularly successful in slowing the reform by frustrating the development of a prospective, risk-adjusted payment mechanism. The resistance of corporatist organizations to the 1974 and 1987 reforms provoked a largely unplanned process of creeping etati-zation. Paradoxically, the present market-oriented reforms coincide with far-reaching state interventions in determining provider fees. A new, more satisfactory balance between corporatism, etatism, and market mechanisms must still be found.
The Impact of German Health Insurance Reforms on Redistribution and the Culture of Solidarity
Authors: Hinrichs Karl
Published: January 2008

The statutory health care scheme represents the most ambitious branch of the German social insurance system because it entails interpersonal redistribution on a large scale. The stability of this centerpiece of the German welfare state thus depends on a “culture of solidarity” to maintain the legitimacy of these redistributions. In this article, the present debate on restructuring the welfare state in general is analyzed. However, the focus is on the ongoing struggle to further reform the health care system. Influential political actors' proposals to depart from universal access to a comprehensive range of health care benefits based solely on medical need and from the earnings-related mode of financing stand in stark contrast to empirical results on insured persons' willingness to support the existing system. Findings from qualitative interviews show that a culture of solidarity still prevails among insured persons. It is argued that lasting political attempts to shift the balance between solidarity and self-reliance in favor of the latter could weaken this moral infrastructure of the welfare state and, as a consequence, the statutory health insurance system could lose its plausibility and attraction. Such a development would ease the reconstruction of the social security system by privatizing parts of currently public expenditures and reducing the scope of interpersonal redistribution.
Health Care Reform in Sweden in the 1990s: Local Pluralism versus National Coordination
Authors: Garpenby Peter
Published: January 2008

Because of the poor state of the Swedish economy, publicly provided health care services, like other welfare services, are increasingly vulnerable to possible cutbacks. A growing discontent among the public in the late 1980s paved the way for experiments with new economic incentives among health care providers. Although many parts of the welfare state are being questioned today, the principle of universal-ism in health care has not been seriously challenged, but support for the present health care system among Swedes depends on how well the system functions. The prospects for implementing major organizational changes in health care through a top-down procedure, however, are limited. The appointment of the Committee on Funding and Organization of Health Care in 1992 by the previous government can be regarded as merely a way to show activity rather than as an instrument to achieve meaningful change.
Health Care Reform in Norway: The End of the “Profession State”?
Authors: Erichsen Vibeke
Published: January 2008

From the early nineteenth century until about 1980, a close relationship developed in Norway between the state and the medical profession. Medicine became integrated into the state at all levels of government, and the profession assumed important roles in initiating and formulating health policy. Another, and perhaps also causally related, development has been that health policyand most strikingly during postwar expansiontended to be formulated and implemented in its own policy sector, with few links to other parts of the welfare state. Important elements of the “profession state” in Norway have thus been professional integration with the state and institutional isolation from other policy sectors. Health reforms of the 1980s and 1990s brought changes in institutional relations: Other professions have replaced physicians as experts at central and local levels, and health policy making has become more politicized and integrated into welfare state policies. Thus there are clear indications that the profession state is waning.
Prevention and Government: Health Policy Making in the United Kingdom and Germany
Authors: Freeman Richard
Published: January 2008

The gap between rhetoric and reality in health policy making for disease prevention services is well recognized. I do not try once more to close the gap, but rather argue that the rhetoric of prevention is politically significant. Beginning with an account of prevailing explanations of prevention in policy making, I explore the idea that prevention has a pervasive legitimacy in health politics. This affords opportunities for instrumental policy making by government. To this end, I concentrate on the relationship between disease prevention and health care delivery, discussing in detail the association between prevention and health care reform. My arguments are based on case studies of policy making in Germany and the United Kingdom. I discuss implications for understanding the core interests of government, physicians, and users with respect to prevention in health policy making. The concluding section offers comparative commentary on the role of disease prevention in health sector restructuring.
The British Health Care Reforms, the American Health Care Revolution, and Purchaser/Provider Contracts
Authors: Jost Timothy Stoltzfus , Hughes David , McHale Jean , Griffiths Lesley
Published: January 2008

The health care systems of the United States and the United Kingdom are changing rapidly. After the Thatcher government’s 1989 white paper, the formerly unified British National Health Service (NHS) was split into purchaser and provider sides, with the NHS District Health Authorities becoming purchasers, and the NHS hospitals, now reconstructed as independent NHS trusts, becoming providers. The U.S. health care system, driven by market forces rather than government fiat, has been moving rapidly toward integration, with increasingly formalized purchaser and provider relationships. Contracts are found at the purchaser/provider interface in both systems. We reviewed American and British purchaser/provider contracts. The contracts address similar issues but often take disparate approaches. These dissimilarities illuminate the profound, continuing differences between the two systems. They also, however, offer possibilities to transfer contracting “technology” between the two contracting cultures.
Voluntary Public Health Insurance for Low-Income Families: The Decision to Enroll
Authors: Madden Carolyn W. , Cheadle Allen , Diehr Paula , Martin Diane P. , Patrick Donald L. , Skillman Susan M.
Published: January 2008

A dominant issue in the health reform debate is whether insurance coverage should be voluntary or mandatory. Clearly, the factors that determine who will seek voluntary coverage are relevant to this policy issue. This article uses experience from Washington State’s Basic Health Plan to examine the enrollment choices of low-income families in a state-subsidized voluntary insurance plan offered through managed care organizations. We hypothesize that the decision to enroll, which encompasses the decisions to purchase insurance coverage and to select a particular plan, is influenced by four factors: the family’s financial vulnerability, their risk perception, the price of coverage, and the transition costs of enrolling. Our enrollment model is supported by the data and has important implications for the design of voluntary programs. Families who choose to enroll are more likely to have a female head of household, young children, and a family member who has a part-time job and some college education. Higher premiums and availability of other insurance coverage decrease the probability of enrolling.
Publicity-Stunt Participation and Sound Bite Polemics: The Health Care Debate 1993–94
Authors: Disch Lisa
Published: January 2008

The outcome of Bill Clinton’s health care initiative presents policy analysts and democratic theorists with a puzzle: How could vigorous discussion of health reform, introduced into the context of an emerging public consensus about its urgency, produce widespread incomprehension of the issue and foster public reluctance to embrace any specific proposal for change? Starting from the perspective of political theories of deliberative democracy, I approach the puzzle of failed health reform by pointing to the paradox of decision making in an adversary democracy. First, I argue that the policy initiative stalled because the debate was set up to depoliticize the question of health reform and thereby disengage citizens from the problem. Second, I defend a conception of “power-sensitive” deliberation, which I argue is a check against two typical mechanisms of depoliticization: factionalism and the “democratic wish.” Third, I suggest four criteria for power-sensitive deliberation, which I then use to analyze the recent health care debates. Finally, I explore the incentives and obstacles to creating opportunities for this kind of deliberation.
Harry and Louise Go to Washington: Political Advertising and Health Care Reform
Authors: West Darrell M. , Heith Diane , Goodwin Chris
Published: January 2008

Political advertising by interest groups trying to influence public policy has proliferated recently. Formerly the preserve of election campaigns, advertising has spread to policy arenas, such as abortion, trade, and health care. This article examines group lobbying for and against President Clinton’s health care reform plan. Using a study of advertisements, a content analysis of news coverage, interviews with half a dozen leading figures in the debate during the spring of 1995, and an analysis of three national public opinion surveys designed to gauge the public response to health care ads, we investigate the media campaign on health care. Ads directed against the Clinton plan played a crucial role in the public’s attaching negative connotations to some of its key elements. Grassroots campaigns can work either by mobilizing public opinion or by persuading political leaders that grassroots opposition exists to a particular program.
Allocating Health Care: Cost-Utility Analysis, Informed Democratic Decision Making, or the Veil of Ignorance?
Authors: Goold Susan D.
Published: January 2008

Assuming that rationing health care is unavoidable, and that it requires moral reasoning, how should we allocate limited health care resources? This question is difficult because our pluralistic, liberal society has no consensus on a conception of distributive justice. In this article I focus on an alternative: Who shall decide how to ration health care, and how shall this be done to respect autonomy, pluralism, liberalism, and fairness? I explore three processes for making rationing decisions: cost-utility analysis, informed democratic decision making, and applications of the veil of ignorance. I evaluate these processes as examples of procedural justice, assuming that there is no outcome considered the most just. I use consent as a criterion to judge competing processes so that rationing decisions are, to some extent, self-imposed. I also examine the processes’ feasibility in our current health care system. Cost-utility analysis does not meet criteria for actual or presumed consent, even if costs and health-related utility could be measured perfectly. Existing structures of government cannot creditably assimilate the information required for sound rationing decisions, and grassroots efforts are not representative. Applications of the veil of ignorance are more useful for identifying principles relevant to health care rationing than for making concrete rationing decisions. I outline a process of decision making, specifically for health care, that relies on substantive, selected representation, respects pluralism, liberalism, and deliberative democracy, and could be implemented at the community or organizational level.
Americans’ Political Participation in the 1993–94 National Health Care Reform Debate
Authors: Brodie Mollyann
Published: January 2008

The health politics and policy communities are still struggling with the question of “what went wrong” in the 1993–94 health care reform effort. Here I identify which Americans were politically active and inactive during the health care reform debate to explore the role political participation may have had in determining the outcome of the debate. Using data from a national and California random-sample telephone surveys, and controlling for other demographic attributes, I found that those who engaged in political activity specifically related to health care reform were disproportionately more likely to be self-identified conservatives, less likely to favor an employer mandate plan, more likely to be fifty to sixty-four years old, more likely to be men, and more likely to have greater interest in and knowledge of the health care issue. Even in California, where a single-payer proposal was on the November ballot, self-identified liberals were no more likely to engage in political activity on health care reform than were moderates or conservatives. I consider implications for the reform outcome given that liberals, the elderly, and those favoring the employer mandate proposal were all disproportionately “silent” during this debate, and finally I discuss the potential for mobilization during future debates.
Physicians’ Personal Malpractice Experiences Are Not Related to Defensive Clinical Practices
Authors: Glassman Peter A. , Rolph John E. , Petersen Laura P. , Bradley Melissa A. , Kravitz Richard L.
Published: January 2008

Whether personal malpractice experience is part of a tort signal prompting physicians to practice defensively is unclear. To explore this issue further, we assessed how physicians’ malpractice experiences affect clinical decision making. We surveyed 1,540 physicians from four specialty groups (cardiologists, surgeons, obstetrician-gynecologists, and internists) using specialty-specific clinical scenarios. Physicians were in active private practice, were covered by a single malpractice insurer for five or more years, and worked in an eastern state. The net response rate was 54 percent (835 of 1,540) but measurable bias, based on practice characteristics, was negligible. Physicians evaluated clinical scenarios that were designed to maximize potential for finding positive defensive practices (extra tests and procedures). Then they rated how various factors influenced their decisions and answered questions on practice attitudes. The study compared management and testing recommendations among physicians with varying levels of malpractice exposure, which we defined in three separate ways. Participants were unaware of the study hypotheses. Physicians with greater malpractice experience showed no systematic differences in initial management choice or subsequent test recommendations. For example, similar percentages of internists in the top and bottom claims rate quartiles admitted a patient with syncope (78 percent versus 73 percent; p = .42), discharged a patient with nonspecific chest pain (80 percent versus 80 percent; p = .88), and delayed surgery in a patient with nonspecific changes on a electrocardiograph (58 percent versus 68 percent; p = .18). Attitudes about malpractice also did not differ with varying malpractice experience. Personal malpractice experience is not a predominant factor in the tort signal that prompts physicians to engage in defensive practices, to the extent that such practices exist.
The Use of Low-Osmolar Contrast Agents: Technological Change and Defensive Medicine
Authors: Jacobson Peter D. , Rosenquist C. John
Published: January 2008

The escalating cost of medical care in the United States, especially in the past decade, has resulted in efforts to identify the factors contributing to rising costs. One factor often assumed to cause higher medical costs is the physician’s fear of liability for not using the latest available technology. In this article, we report the results of a case study we conducted to better understand the relationship between the introduction and use of one particular technology, low-osmolar contrast agents, and liability concerns. Our study suggests that both clinicians and administrators are primarily guided by the medical benefits of low-osmolar contrast agents, and that liability concerns, although widespread, are of secondary importance. The inability to control this and similar technologies is likely to put a far greater strain on the nation’s health care resources than is the practice of defensive medicine. These findings may be helpful to health policy makers, physicians, administrators, and legislators considering choices for health care reform in general and for medical liability reform in particular.
Medical Practice Guidelines in Malpractice Litigation: An Early Retrospective
Authors: Hyams Andrew L. , Shapiro David W. , Brennan Troyen A.
Published: January 2008

The role of practice guidelines in malpractice litigation has been discussed in some theoretical detail. Little information is available, however, on how courts use guidelines or on the effort of state legislatures to explicitly link guideline compliance with malpractice defenses. We review all relevant case law and legislative enactments to shed light on the influence of medical malpractice on guidelines. We also use data from a nationwide survey of malpractice attorneys to supplement our legal analysis. Although guidelines are being used for both inculpatory and exculpatory purposes in common-law litigation (a two-way street), legislatures are interested in applying them only for exculpatory purposes (a one-way street).
Medical Malpractice in Michigan: An Economic Analysis
Authors: Spurr Stephen J. , Simmons Walter O.
Published: January 2008

We analyzed the factors determining the amount of the recovery on claims based on medical malpractice. Our data set, which previously was not explored, consists of 20,428 claims arising within Michigan that were closed between 1978 and 1990. During this period, major changes were made in the law governing malpractice litigation. We determine the effect of these changes and of various other factors affecting medical malpractice claims. We analyze the effect of a statute that was designed to curtail “forum shopping” by attorneys for plaintiffs. This statute was initially successful in curbing such activity, but its effect seems to be diminishing. In addition, we compare mediation awards with settlement payments, and settlement payments with the expected value of claims in litigation. Evidence suggests that a mediation award is the mediation panel’s estimate of a settlement payment appropriate for the case, and that cases are settled for substantially less than their expected value at trial.
Medicaid Managed Care and the Health Reform Debate: Lessons from New York and California
Authors: Sparer Michael S.
Published: January 2008

Nearly every state now encourages (or requires) its Medicaid beneficiaries to enroll in managed care. There is, however, extraordinary variation in every aspect of state managed care policy. In this article, I examine the managed care initiatives of two states, New York and California, and focus on variation in state policy-making environments and on the influence of such variation on efforts to protect the medical safety net. I conclude that California’s managed care initiative is less decentralized and pluralistic than New York’s, and that California has used its discretion to adopt a strategy designed in part to protect safety-net hospitals. I end with a plea for greater federal control of managed care initiatives, a policy proposal that is at odds with the current trend to increase state authority.
Redefining Rate Regulation in a Competitive Environment
Authors: Wallack Stanley S. , Skwara Kathleen Carley , Cai John
Published: January 2008

Neither rate regulation nor market competition alone is likely to contain health care spending in the long run. We need an approach to cost containment that can simultaneously address the major causes of rising health expenditures: higher prices, greater intensity, and new technologies. Whereas rate regulation and market competition have been viewed as alternative strategies, an innovative approach would include a rate-regulatory system that is compatible with an evolving competitive market. We discuss the Maryland hospital rate-setting system as an illustration of the compatibility of a regulatory approach within a competitive market. In addition, we consider the feasibility of expanding a hospital rate-setting system nationwide and to the nonhospital sectors.