bluuebunny/crossref_metadata_2025 huggingface dataset:
“I'll Never Have a Clown in My House” — Why Movie Horror Lives On
Authors: Cantor Joanne
Published: December 2005

To explore lingering effects of frightening media, 530 papers written by students over a three-year period (1997-2000) were reviewed. The students could write about their own fright reactions or about a response they had witnessed in another person. Almost all students (93 percent) wrote about their own experiences, and the overwhelming majority (91 percent) described reactions to realistic fiction or fantasy content (depicting impossible events) rather than to the news or a documentary. The ninety-one papers about the four presentations cited most frequently— Jaws, Poltergeist, The Blair Witch Project, and Scream—were content analyzed. Of the papers, 46 percent reported an effect on bedtime behavior (e.g., sleep disturbances) and 75 percent reported effects on waking life (e.g., anxiety in related situations). Among the prominent effects on waking life were difficulty swimming after Jaws (in lakes and pools as well as the ocean); uneasiness around clowns, televisions, and trees afterPoltergeist; avoidance of camping and the woods following The Blair Witch Project; and anxiety when home alone after Scream. More than one-third of the papers reported effects continuing to the time of the study. These consequences attest to the enduring power of emotional memory even when the viewer is aware that the response is to a large extent irrational. Possible reasons for these lingering effects are discussed.
“Please Help Me; All I Want to Know Is: Is It Real or Not?”: How Recipients View the Reality Status ofThe Blair Witch Project
Authors: Schreier Margrit
Published: December 2005

This article is concerned with how recipients evaluate the reality status of media products, how they distinguish and how they interrelate elements of“fact” and “fiction.” On the basis of an overview of recent theories of fictionality, an approach comprising three independent perspectives for evaluating the reality status of media products is proposed:a pragmatic perspective concerning the product type (“fact,”“fiction,” and “hybrids”), a semantic perspective concerning product content (degrees of plausibility), and a perspective of mode referring to the (perceived) realism of the product (formal features and their effects on degree of involvement). Under all three perspectives, a media product will usually contain cues that orient the recipient toward ontic status, plausibility of content, and so forth. This model is then applied to a media product transcending the traditional boundaries between“fact” and “fiction,” the pseudodocumentary horror film The Blair Witch Project and its reception. To study the reception, a random sample of e-mails from Internet newsgroup discussions of the film is subjected to content analysis. A first analysis shows that among those e-mails written within six months after the release of the film, 38 percent refer to questions concerning its reality status. A second analysis explores the perspectives from which this reality status is discussed and whether the recipients regard the film as fiction or as nonfiction. While most discussants correctly identify it as fiction, almost 40 percent are at least temporarily uncertain as to the product type. To substantiate their perceptions of or their doubts concerning the film's ontic status, both recipients that consider it to be fiction and recipients who are uncertain frequently refer to information gathered from other media. By comparison, cues that permit the unambiguous identification of the film as fiction (impossible content elements, disclaimer as part of the credits) are only rarely given as reasons. These results show that novel, unfamiliar hybrid genres have the potential to confuse recipients and thus temporarily provide a way for“fiction” to enter “life.”
Portable Monuments: Literature, Cultural Memory, and the Case of Jeanie Deans
Authors: Rigney Ann
Published: December 2005

This article seeks to contribute to contemporary discussions on the workings of cultural memory and examines in particular the way in which literary texts can function as a social framework for memory. Through a detailed study of the genesis, composition, and long-term reception of Walter Scott's The Heart of Midlothian (1982 [1818]), I argue that literary texts play a variety of roles in the formation of cultural memory and that these roles are linked to their status as public discourse, to their fictional and poetical qualities, and to their longevity. This analysis of the multiple roles of literary texts in what I call “memorial dynamics” sheds light on the complex communicative processes by which images of the past are formed and transformed over time. It indicates the need to consider discontinuity as a feature of memorial dynamics and to recognize, for better or for worse, that fictionality and poeticity are an integral and not merely“inauthentic” feature of cultural memory.
A Poetics of Coincidence in Narrative Fiction
Authors: Dannenberg Hilary P.
Published: December 2005

In the major form of the traditional coincidence plot, estranged relatives meet in remarkable circumstances. In complex representations, the central aspect is cognitive and involves a recognition scene in which the estranged characters discover each other's identity. An analysis of this narrative core of the coincidence plot centers on the depiction of the characters' cognitive processes and the suspense generated by the reader's anticipation of a recognition scene. Beyond this, the narrative explanation of coincidence is a key feature: a variety of explanatory patterns, frequently involving causality, are invoked to naturalize the narrative strategy and conceal the authorial manipulation that lies behind it. The traditional coincidence plot is a key plot feature in varying manifestations from the Renaissance to the postmodernist novel; however, modernist and postmodernist fictions also developed their own specific forms of coincidence involving analogical relationships of correspondence. Both in the question of recognition and explanation, this new form of literary coincidence differs substantially from traditional coincidence, notably because of its subversion of the causal explanatory systems and of linear patterns of origin which form a central part of the traditional coincidence plot.
Dialogical Reading in the Rabbinic Exegetical Narrative
Authors: Levinson Joshua
Published: December 2005

This article investigates the reading dynamics of the rewritten Bible or the exegetical narrative in rabbinic literature of late antiquity. The exegetical narrative is composed of a story which simultaneously represents and interprets its biblical counterpart. Its singularity resides precisely in this synergy of narrative and exegesis. As exegesis, it creates new meanings from the biblical verses, and as narrative, it dramatizes those meanings by means of the biblical story world. The concurrent presence of two distinct voices, biblical and rabbinic, as well as two distinct types of discourse,narrative and exegetical, that navigate between these voices, creates a unique type of reading dynamic that I call dialogical reading. It is this dynamic that enables the midrashic text to create new meanings from old and highlights the challenge this genre presents to the theory of reading.
On Literature and Ethics
Authors: Eskin Michael
Published: December 2005

This essay deals with the complex relationship between literature and ethics. More specifically, it inquires into and problematizes the conceptual ways in which such discursive distinctions as that between literature and moral philosophy have been upheld, as well as the assumptions and presuppositions underlying the ascription to literature of an ethically exemplary role. Accepting the methodological and conceptual challenges presented by some of the major philosophical and theoretical positions informing literature's perception as ethically exemplary (from Aristotle to Jakobson and Derrida), this essay suggests a new theoretical framework for thinking about the enmeshment of literature and ethics, drawing especially on the works of Bakhtin and MacIntyre.
Ethics as Style: Wittgenstein's Aesthetic Ethics and Ethical Aesthetics
Authors: Stengel Kathrin
Published: December 2005

An inquiry into Wittgenstein's ethics and aesthetics has to start with the following questions: Can an aesthetics and/or ethics be extracted from his philosophical texts at all? If yes, what kind of aesthetics and/or ethics does Wittgenstein offer beyond his well-known aphoristic comments on the subject?Finally, how can we understand the meaning of his claim that “ethics and aesthetics are one”? This article responds to the above questions by presenting an account of Wittgenstein's ethical aesthetics and aesthetic ethics, elucidating both through the prism of his notion of style as“general necessity seen sub specie eterni.” It explains how logical necessity implodes within the limits of propositional language to open onto the realm of style, within which ethical necessity is to be understood in terms of aesthetic life-form and aesthetic expression is to be understood in terms of ethical enactment.
“Faint with Secret Knowledge”: Love and Vision in Murdoch'sThe Black Prince
Authors: Nussbaum Martha
Published: December 2005

Erotic love both illuminates and blinds. In The Black Prince,perhaps her most insightful novel about love, Iris Murdoch shows us both facets of erotic love in operation. On the one hand, Bradley's love and the anxiety that is closely related to it blind him to many features of the people around him, as the ego so often, in Murdoch's view, obscures reality. On the other hand, love also supplies real insight, and Murdoch, closely following Plato's Phaedrus, shows how Bradley's passion for Julian forces him out of himself, enabling him to see much more than he had previously seen. I investigate the tension between these two aspects of erotic love, as the novel presents them, and examine the relationship between Murdoch's philosophical arguments about love and the complexities of her fiction.
Rilke's Imperatives
Authors: Waters William
Published: December 2005

Critics have warned readers against feeling personally addressed by the many commands in Rilke's Duino Elegies and Sonnets to Orpheus. The essay argues, through readings of imperative sonnets, that such critics are misguided: the poems do seek a reader's intimate and personal reception. Since the commands in question concern ethical stances and the self-knowledge of the addressed you, deflecting them from yourself as reader deflects the power of the aesthetic to make you change your life. The anxious strain in Rilke criticism is then related, through a reading of Rilke's poem “Snake-Charming,” to views of Rilke as an effeminate man. Male critics' warding gestures when confronted with Rilke's imperatives—the caution lest this seductive man touch us—resembles male homosexual panic, the alarm of men confronted with male desire. The essay's broader point concerns our vulnerability to literature and the part that vulnerability plays in literature's ethical force.
Prose and Poetry: Wimsatt's Verbal Icon and the Romantic Poetics of New Criticism
Authors: Friedberg Harris
Published: December 2005

Foremost theorist of the New Criticism, W. K. Wimsatt, inherits from the Romantics the desire to differentiate poetry from prose on essentialist rather than formal grounds. In I. A. Richards, a new antithesis between the symbolic or referential use of language and its emotive use replaces the old one of prose and poetry. Wimsatt also recognizes two kingdoms of discourse, but for him, a formal or functional difference—the complementary distribution of the logical and counterlogical figures—confirms that poetry and prose really do differ: “the difference between prose and verse is the difference between homoeoteleuton and rhyme.” Neither prose nor poetry, however, observes the divide between logical and counterlogical figures with anything like the regularity claimed by Wimsatt. Examples of rhyme in prose and homoeoteleuton in verse weaken his case, as does the example of John Milton's enjambed blank verse, with the sense variously drawn out, which emulates the periodic syntax of Milton's own prose. The attempt to differentiate the logical language of prose from the emotive, counterlogical language of poetry, which the New Critics silently adopt from the Romantics, fails, and, historically, the project of finding the essential difference gives way to Roman Jakobson's notion of the poetic function, dominant in poetry but available to prose as well.
Fiction and Silence as Testimony: The Rhetoric of Holocaust in Dan Pagis
Authors: Yacobi Tamar
Published: December 2005

In both real-life and fictional testimony, the problems of reliability-judgment multiply when witnesses report events that count as extraordinary. Historians and other judges then suspect the teller of misrepresentation. On such testimonies there accordingly converge the issues of reliability and rhetoric, truth and persuasion, norm and narrative discourse. To illustrate them, my essay juxtaposes the testimonial viewpoints and practices of two survivors of the Nazi camps: Primo Levi and Dan Pagis. The two may seem poles apart: while Levi is considered the quintessential witness, Pagis chose silence, just as his poems of fantasy stand opposed to Levi's documentary prose. Yet the comparison remains illuminating because even the divides prove thematic, central, and even dynamic, in that the writers undergo a symmetrical change. While the early Levi is relatively optimistic about the success of his project, his last book, The Drowned and the Saved,expresses a great disillusionment about his life's work as a witness to the Holocaust. The change can be traced, first, to his growing doubts about the reliability of witnesses, and second, to the reactions of readers, which made him question the very human capacity to understand whatever lies beyond one's own horizon of experience. Over the years, either party to the dialogue has turned out, or become, unequal to its demanding role.

Pagis's alternative strategy of communication—fictional, poetic,implicit—is the focus of the argument. The Holocaust surfaces as late as his third book, mainly in a small group of poems. Their dense and subtle poetic composition functions for rhetorical, notably testimonial ends. Equally important is the fictionalizing of both the world and the discourse about it. A twofold dialogic process (inset versus framing) ensues, whereby we catch a glimpse of Pagis's own viewpoint on the subject he otherwise avoided. In rejecting typical witnessing material and techniques, Pagis changesthe very priorities of representation, from the standard problematic frontal attack to a defamiliarizing obliquity heightened by the resources of fantasy. Likewise with the shift from victim/victimizer relations as witnessed nowadays by a participant to their earliest precedents in the Abel/Cain affair and, more generally, to their sources in a God-created humankind. By this boldest departure, the target of attack itself ascends, or extends, from earth to heaven, and with it everything else. This strategy is exemplified and further generalized from the two poems that not only carry it to a limit but also thematize the issue of testimony in the process, beginning with their titles:“Testimony” and “Another Testimony.” Through such odd-looking obliquities, I conclude, Primo Levi's unachievable ideal (as opposed to his splendid documentary performance) is realized in Pagis's bold fictions of testimony.
Target Audience, Hurdle Audience, and the General Reader: Varlam Shalamov's Art of Testimony
Authors: Toker Leona
Published: December 2005

Literary testimony combines the pragmatic function of attesting to historical events with the aesthetic function that becomes marked after their function as testimony has become redundant. Whereas the social identity of the target audience addressed impinges upon the shape of the work, the features of the address may be part of the work's abiding aesthetic value. The shape of the work is also sometimes affected by the need to circumvent the hurdle audience, that is, official or unofficial censorship that can obstruct its accessibility to the target audience. With the help of brief references to Aleksandr Solzhenitsyn and Anatolii Zhigulin, this essay shows how the address to the target audience and the circumvention of the hurdle audience can influence the shape of works of testimony. It then turns to the complex relationship between the target audience and the general reader in the Gulag stories of Varlam Shalamov.
Place Deixis and the Schematics of Imagined Space: Milton to Keats
Authors: Bruhn Mark J.
Published: December 2005

The infrequent, indefinite, and cumulatively incoherent use of place deixis in the representation even of conceptually unified space is characteristic of the greater English lyric from Milton through the eighteenth century. In these poems, as Balz Engler has suggested, such deixis typically operates for the rhetorical sequencing of entities conceived as themes, rather than for the grounding and interrelation of entities conceived as objects within a represented scene. With the advent of romanticism, however, place deixis begins to appear with greater frequency, density, and variety, to trifold effect. It consolidates the represented scene, collapses that scene with the situation-of-discourse, and thereby reorients lyric attention to the local,relative, and embodied. Adapting recent arguments in spatial cognition and cognitive grammar, this study first describes the general functions of place-deictic schemata in literary cognition and then analyzes their poetic fortunes in relation to the concept of lyric sublimity from Milton to Keats.
The Jury Is Still In: Florida's Birth-Related Neurological Injury Compensation Plan after a Decade
Authors: Studdert David M. , Fritz Lori A. , Brennan Troyen A.
Published: December 2005

Florida's Birth-Related Neurological Injury Compensation Plan (NICA) is the most significant experiment with compensation for medical injury yet undertaken in the United States. As NICA enters its second decade of operation, maintaining the scheme's jurisdictional integrity has emerged as a key challenge for policy makers in Florida. We explore the relationship that has emerged between NICA and the tort system as competing avenues for families to obtain compensation for severe birth-related neurological injury. By linking NICA claims data with data on malpractice claims filed in Florida, we found a lively persistence of “bad baby” litigation despite NICA's implementation. Many families pursued claims in both fora. An explanation for these results can be traced to key features of the plan's design—primarily, the way in which “exclusive” jurisdiction over injuries is determined and the restrictive nature of the compensation criteria used. Our findings may help efforts to consolidate NICA's role in injury compensation and inform future design of alternative compensation systems.
School-Based Mental Health Program Development: A Case Study of Interorganizational Collaboration
Authors: Kastan John
Published: December 2005

Because of increased competition and financial pressure, more and more contemporary health care organizations are forming (or attempting to form)collaborative ventures. In the early 1980s, the New York City Board of Education and the New York City Department of Mental Health planned and implemented a collaborative program in the city's schools for an on-site school mental health program.In this article, I explore the difficult and attenuated process of interorganizational collaboration-including attention to the organizational, political, and interprofessional context within which such ventures are implemented-to examine how such cooperative program development can be successfully accomplished in today's competitive and complex health care arena.
The Social Roles of Medicare: Assessing Medicare's Collateral Benefits
Authors: Gusmano Michael , Schlesinger Mark
Published: December 2005

The Medicare program incorporates a number of functions that go beyond providing health insurance to its beneficiaries. These activities, which we refer to as “collateral” functions, may have important health consequences but are also an increasing source of controversy. In this essay we develop a conceptual framework for categorizing these involvements,introduce some additional options that might complement Medicare's current collateral functions, assess the reaction of policy elites and Medicare's current beneficiaries to these alternatives, and evaluate the role that collateral activities play for Medicare's core mission. A case can be made for expanding some collateral involvements, but only if the Health Care Financing Administration has the strategic direction and administrative capacity to effectively implement these activities.
Expertise in Law, Medicine, and Health Care
Authors: Shuman Daniel W.
Published: December 2005

As the practice of science-based medical evidence has challenged the medical profession to consider the scientific bases for its methods and procedures, on a seemingly parallel path, the United States Supreme Court's 1993 decision in Daubert v. Merrell Dow Pharmaceuticals has challenged the legal system to consider the science underlying claims of medical expertise. This article examines how the legal system has responded to that challenge and why the response has been more limited than many had expected; the implications of the legal system's approach to scrutiny of claims of medical expertise for the practice of science-based medical evidence; and, the central elements of any meaningful change in legal assessments of expertise in medicine and health care.
Medical Savings Accounts in Singapore: A Critical Inquiry
Authors: Barr Michael D.
Published: December 2005

With the United States currently experimenting with medical savings accounts (MSAs), it is appropriate to revisit the Singapore experience, where the practice has been in place for a decade and half. Singapore runs a modern,effective health system at a fraction of the cost of most systems operating in the developed West. Although MSAs contribute to the framework of a cultural rhetoric of personal responsibility for health care, this article argues that the heart of the Singapore system of health funding, with its financial discipline, is government control of inputs and outputs and strict rationing of health services according to wealth.
Responding to Chemical, Biological, or Nuclear Terrorism: The Indirect and Long-Term Health Effects May Present the Greatest Challenge
Authors: Hyams Kenneth C. , Murphy Frances M. , Wessely Simon
Published: December 2005

The possibility of terrorists employing chemical, biological, or nuclear/radiological (CBN) materials has been a concern since 1995 when sarin gas was dispersed in a Tokyo subway. Contingency planning almost exclusively involved detection, containment, and emergency health care for mass casualties. However, it is clear that even small-scale CBN incidents—like the recent spread of anthrax spores through the mail—can cause widespread confusion, fear, and psychological stress that have lasting effects on the health of affected communities and on a nation's sense of well-being. More emphasis therefore needs to be placed on indirect effects and on the medical, social, economic, and legal consequences that follow months to years afterward. To respond effectively to CBN attacks, a comprehensive strategy needs to be developed that includes not only emergency response, but also long-term health care, risk communication, research, and economic assistance. Organizing an effective response challenges government institutions because the issues involved—eligibility for health care,the effects of low-level exposure to toxic agents, stress-related illnesses,unlicensed therapeutics, financial compensation—are complex and controversial.
Consumer Beliefs and Health Plan Performance: It's Not Whether You Are in an HMO but Whether You Think You Are
Authors: Reschovsky James D. , Hargraves J. Lee , Smith Albert F.
Published: December 2005

Surveys that rate how persons enrolled in HMOs and other types of health coverage feel about their health care are used to bolster claims that HMOs provide inferior quality care, providing justification for patient protection legislation. This research illustrates that the conventional wisdom regarding inferior care in HMOs may color how people assess their health care in surveys, resulting in survey findings biased toward showing HMOs provide inferior care and reinforcing existing stereotypes. Using merged data from the Community Tracking Study Household and Insurance Followback surveys, we identify privately insured persons who correctly and incorrectly know what kind of health plan they are covered by. Nearly a quarter misidentified their type of health coverage. Differences between responses by HMO and non-HMO enrollees to questions covering satisfaction with health care and physician choice, the quality of the last physician's visit, and patient trust in their physician shrink or disappear when we control for beliefs about what type of plan they are covered by. Results suggest that researchers and policy makers should be cautious about using consumer surveys to assess the relative quality of care provided under different types of health insurance.
The Use of Expensive Health Technologies in the Era of Managed Care: The Remarkable Case of Neonatal Intensive Care
Authors: Friedman Bernard , Devers Kelly J. , Steiner Claudia A. , Fox Steven
Published: December 2005

The use of neonatal intensive care (NIC) continued to rise rapidly in the 1990s despite the concerns of observers about its cost effectiveness and its successes being mostly in facilities with high volume and capabilities. The objective of this study is to test the effects of insurance type, competition among hospitals, and market pressure from managed care plans on the supply and cost of NIC. The analysis uses logistic and linear models with techniques to avoid bias from (a) market area definitions based on actual patient flows and(b) self-selection of hospitals by patients with unmeasured risk of needing NIC. The data source contains all births in short-term hospitals in New Jersey during 1990 and 1994. Both the number of days and charges for NIC are reported. Key findings are that the decision of a hospital to offer NIC was associated with teaching status, the proportion of infants in the market area with documented high risk, and the market concentration of major competitors. The market share of managed care plans and the concentration of enrollment were not associated with either NIC being offered or with the standardized charges. Whether a particular patient was given to a NIC depended on patient risk factors and whether a NIC unit was present, but not on payer group. The results are consistent with the hypothesis that young insured parents (with the advice of their obstetricians) prefer hospitals with NIC and also are relatively profitable enrollees for health plans. In conclusion: using the results here and in other research, public and private policy makers may consider several ways to strengthen the incentives for health plans to contract for cost-effective birth-related services. The results also raise questions for a number of regulatory and payment policies and call for better public data on costs and outcomes for NIC.
Will Physician Unions Improve Health System Performance?
Authors: Brewbaker William S.
Published: December 2005

In the public debate over the extension of collective bargaining rights to independent physicians, union proponents' primary argument has been that patients would benefit from allowing physicians to bargain collectively with health plans. This article examines the likely effects of physician unions on the U.S. health care system. Specifically considered are likely effects on economic efficiency, quality, access, and cost. Under none of these criteria are physician unions likely to improve health system performance, particularly when compared with available alternative strategies for dealing with problems identified by union proponents.
Why Medicare Cannot Promulgate a National Coverage Rule: A Case ofRegula Mortis
Authors: Foote Susan Bartlett
Published: December 2005

For over twenty-five years, Medicare has tried to promulgate a rule to implement the broad congressional directive to pay only for items and services that are “reasonable and necessary” A rule would clarify legal authority and describe specific criteria for evaluation of new technology in Medicare. This case study is an intractable example of a larger issue ofregula mortis or dead rule. Regula mortis occurs when a mobilized interest group blocks legitimate administrative agency action, causing a regulatory stalemate. In this case, the medical device industry has prevented the implementation of a rule. The article diagnoses the condition of regula mortis, explains its effects in the Medicare case, and draws on principles of administrative law to propose remedies to break the logjam.

While the case of coverage criteria is important in its own right, it has wider relevance. All health systems must grapple with the challenge of evaluating new technologies. Medicare efforts provide a starting point for the policy discussion. In our current political environment, regula mortis may be an increasingly common phenomenon and the proposed cures for it broadly applicable.
The Role of Group Interest, Identity, and Stigma in Determining Mental Health Policy Preferences
Authors: McSween Jean L.
Published: December 2005

Public attitudes toward mental health present an interesting puzzle. While mental health is one aspect of general health and well-being, it receives less support for government spending increases than does health care. One explanation lies with the stigma that is attached to mental illness. This stigma produces more negative attitudes on policy issues related to persons with mental illness such as government spending for mental health. However,group identification, as defined by personal experience or a family member who has experienced a mental illness, may have a strong effect on these attitudes. Using data from the 1996 General Social Survey's module on mental health, I examine this and other hypotheses and find evidence that group identification increases the likelihood of increased support for government spending for mental health. These robust findings exist even in quantitative models, which include politically relevant variables and measure identification with mental illness in two different ways. These findings suggest that mental health is policy for the few because those most supportive of government spending increases are persons who share the common identity of experiencing mental illness.
Challenging Pharmaceutical Industry Political Power in Maine and Vermont
Authors: Castellblanch Ramón
Published: December 2005

A comparison of the Vermont and Maine cases of attempting to control pharmaceutical prices in the year 2000 shows that the Maine legislators were more successful in challenging pharmaceutical industry political power. This comparison shows that challenging the industry was aided by (1) mobilizing public support through grassroots organizations, (2) including independent pharmacists in negotiations over the legislation, and (3) developing state purchasing power leverage.
Power to the People? Restoring Citizen Participation
Authors: Morone James A. , Kilbreth Elizabeth H.
Published: December 2005

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.
Reform and Remembrance: The Place of the Private Sector in the Future of Health Care Policy
Authors: Reeher Grant
Published: December 2005

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.
Has Solidarity Survived? A Comparative Analysis of the Effect of Social Health Insurance Reform in Four European Countries
Authors: Maarse Hans , Paulus Aggie
Published: December 2005

Social health insurance reform has evolved as an important public policy issue in several European countries. Some of the most important reform programs have been the introduction of managed competition, a shift from full retrospective reimbursement of health insurers to prospective reimbursement,an increase of private payments, and a change in the health benefits of social health insurance. The article investigates the widespread assumption that reform programs have adverse effects on solidarity in social health insurance by looking at the concrete experience of four European countries (Belgium,Germany, the Netherlands, and Switzerland) over the past decade. A distinction is made between risk solidarity and income solidarity, and the scope of solidarity is shown to have two dimensions: entitlements and membership. The analysis consists of three parts: description of the structure of health insurance of each of the four countries in the early 1990s; discussion of health insurance reform; determination of the impact on each dimension of solidarity. The findings are mixed. There are indeed some examples of solidarity having declined as the result of health insurance reform. But, more important, many examples also were found of an increase in solidarity due to health insurance reform. In some cases, reform was explicitly intended to improve solidarity. If a reform program had a negative impact on solidarity(e.g., an increase in private payments), accompanying measures often were taken to keep solidarity intact as much as possible. Thus the assumption of a negative impact as a result of health insurance reform is not confirmed.
Health Care and the Labor Market: Learning from the German Experience
Authors: Amelung Volker , Glied Sherry , Topan Angelina
Published: December 2005

Many observers have begun to question the U.S. reliance on an employment-based private health insurance system. In thinking about the future of this system, it is instructive to examine the German experience. The German health insurance system is almost entirely organized and financed around the labor market. In recent years, the German labor market has changed in several ways. Among other changes, more German women now work, the proportion of retirees in the population has increased, the share of manufacturing in employment has declined, and the economy has become more open. These labor market changes have made it more difficult to organize health insurance around employment in Germany. Recent changes in the German health insurance system have, to some extent, decoupled health insurance from employment. This decoupling is likely to continue as the labor market changes further. We explore the implications of this experience for the United States.
Commodifying Life? A Pilot Study of Opinions Regarding Financial Incentives for Organ Donation
Authors: Evans John H.
Published: December 2005

In recent years many policy proposals have been put forward to create financial incentives to encourage families to allow the harvesting of organs from their deceased relatives. While research has focused on whether these policies would actually increase the supply of organs, no research has focused on testing the ethical concerns about such policies. This article presents the findings of a pilot study conducted to determine whether people think that families should end life support of a family member in order to harvest organs if various incentive policies are in place. While the findings do not suggest a direct effect of these inducements, they do indicate that the amount of money received from organ donation is a consideration in making the decision whether to end life support. The implications of this finding for ethical debates and health policy are reviewed.
Holding Back the Tide: Policies to Preserve and Reconstruct Health Insurance Coverage in Maryland
Authors: Oliver Thomas R.
Published: December 2005

Over the past decade, state officials have pursued a variety of strategies to protect and expand health insurance coverage for their residents. This article examines the course of action in Maryland, where new initiatives were shaped around the state's unique hospital payment system and its reimbursement of uncompensated care, an evolving Medicaid and children's health program, and regulation of the small group health insurance market. Several important patterns emerge from the Maryland experience. First, even the most incremental initiatives—programs intended to aid a few thousand beneficiaries—bring into play the very issues that hamper comprehensive reforms: who is deserving of mutual aid and what is the proper role of government versus private entities in administering that aid. In Maryland,these issues generate conflict not only between Democrats and Republicans but also urban and rural interests. Second, all of the important reforms of the past decade were undertaken primarily in reaction to federal policy initiatives. Contrary to rhetoric lauding states as the “laboratories of democracy,” the political impetus for reform and basic policy options emerge from interaction between federal and state debates. Third, even with budget surpluses and Democrats in control of the governorship and legislature,Maryland did not move aggressively toward universal health insurance. Now,with a much weaker economy and a new, Republican governor, the primary challenge will be to prevent further erosion of insurance coverage. The Maryland experience reiterates that each step toward greater health security,no matter how small, is a major technical and political challenge and that it will be difficult if not impossible to rely on states to secure coverage for all Americans in the foreseeable future.
Obstacles to Dependent Health Care Access in Oregon: Health Insurance or Health Care?
Authors: Leichter Howard
Published: December 2005

In the 1980s, Oregon was one of a handful of “states that could not wait” for national health care reform. Oregon's chosen approach to reform was predicated on two widely accepted assumptions. First, universal access to health care is best achieved by universal access to health insurance. Second, universal access to health care could best be achieved, at least politically, by incrementally building upon the existing health care delivery and insurance system. This article questions both of these assumptions in light of Oregon's decade-long experience in trying to expand access to health care among its dependent population.
Enrolling Children in Public Insurance: Schip, Medicaid, and State Implementation
Authors: Kronebusch Karl , Elbel Brian
Published: December 2005

The Balanced Budget Act of 1997 established federal grants to the states to create the State Children's Health Insurance Program (SCHIP). This presented the states with a number of implementation choices concerning administrative models for the new programs, as well as choices about eligibility standards,enrollment simplification, crowd-out, and cost sharing requirements. At the same time, the states were also implementing welfare reform. We describe the most important of these implementation choices, and using data from the Current Population Survey, we estimate the impacts of state policy on enrollment in this multiprogram environment. The results indicate that SCHIP programs that are administered as Medicaid expansions are more successful than either separate SCHIP plans or combination programs in enrolling children. States that remove asset tests and implement presumptive eligibility and self-declaration of income have higher enrollment levels. Continuous eligibility and adoption of mail-in applications have no effect on overall enrollment. Waiting periods and premiums reduce enrollment. Stringent welfare reform reduces children's enrollment, despite federal policy that was intended to protect children from the consequences of welfare reform. The negative impacts of a number of these policy reforms substantially reduce enrollment,potentially offsetting the more favorable impacts of other policy choices. We estimate that if all states adopted the policy options that facilitate program use, enrollment for children with family incomes less than 200 percent of the poverty line could be raised from the current rate of 42 percent to 58 percent.
Mental Competence and End-of-Life Decision Making: Death Row Volunteering and Euthanasia
Authors: Harrington C. Lee
Published: December 2005

This article reports on a qualitative study of defense attorneys'perceptions of the mental competence or rationality of death row inmates'decisions to waive habeas appeals and proceed directly to execution. Interviews were conducted with twenty attorneys who have either directly represented or been closely involved with would-be volunteers. Through analytic comparison with another end-of-life decision, euthanasia, this article reports on four themes from the interviews: (a) attorneys' perceptions of the legal standard of competence, (b) their perceptions of the competency evaluation process, (c) implications of competing interpretive frames (i.e.,volunteering vs. suicide), and (d) the rationality of decisions to waive appeals. Implications of research findings, particularly in terms of recent restructured models of competence, are also discussed.
Prospects for Health Impact Assessment in the United States: New and Improved Environmental Impact Assessment or Something Different?
Authors: Cole Brian L. , Wilhelm Michelle , Long Peter V. , Fielding Jonathan E. , Kominski Gerald , Morgenstern Hal
Published: December 2005

Health impact assessment (HIA) has been advanced as a means of bringing potential health impacts to the attention of policy makers, particularly in sectors where health impacts may not otherwise be considered. This article examines lessons for HIA in the United States from the related and relatively well-developed field of environmental impact assessment (EIA). We reviewed the EIA literature and conducted twenty phone interviews with EIA professionals. Successes of EIA cited by respondents included integration of environmental goals into decision making, improved planning, and greater transparency and public involvement. Reported shortcomings included the length and complexity of EIA documents, limited and adversarial public participation, and an emphasis on procedure over substance. Presently, EIAs consider few, if any,health outcomes. Respondents differed on the prospects for HIA. Most agreed that HIA could contribute to EIA in several areas, including assessment of cumulative impacts and impacts to environmental justice. Reasons given for not incorporating HIA into EIA were uncertainties about interpreting estimated health impacts, that EIA documents would become even longer and more complicated, and that HIA would gain little from the procedural and legal emphasis in EIA. We conclude that for HIA to advance, whether as part of or separate from EIA, well-formulated methodologies need to be developed and tested in real-world situations. When possible, HIA should build on the methods that have been utilized successfully in EIA. The most fruitful avenue is demonstration projects that test, refine, and demonstrate different methods and models to maximize their utility and acceptance.
Fostering Rational Regulation of Patient Safety
Authors: Mello Michelle M. , Kelly Carly N. , Brennan Troyen A.
Published: December 2005

After decades of inattention to the problem of medical injuries, patient safety is now occupying a prominent place on the health policy agenda and garnering renewed regulatory interest. Health care providers' behavior, with respect to patient safety and health care quality improvement, is now being shaped by top-down regulation through statutes and administrative agency oversight, as well as bottom-up drivers such as tort litigation and the forces of the consumer-driven health care market. Patient safety today exemplifies that eclectic mix of regulation that can occur when a new problem is exposed to the general public; it also demonstrates the diffi culties of coordinating regulatory signals from multiple sources and regulating incomplete information. This article reviews the evolution of the regulatory environment for patient safety, examines some of the tensions and challenges that currently define patient safety oversight, and suggests strategies for more rational and responsive regulation.
The Who, What, and Why of Risk Adjustment: A Technology on the Cusp of Adoption
Authors: Blumenthal David , Weissman Joel S. , Wachterman Melissa , Weil Evette , Stafford Randall S. , Perrin James M. , Ferris Timothy G. , Kuhlthau Karen , Kaushal Rainu , Iezzoni Lisa I.
Published: December 2005

Risk adjustment (RA) consists of a series of techniques that account for the health status of patients when predicting or explaining costs of health care for defined populations or for evaluating retrospectively the performance of providers who care for them. Although the federal government seems to have settled on an approach to RA for Medicare Advantage programs, adoption and implementation of RA techniques elsewhere have proceeded much more slowly than was anticipated. This article examines factors affecting the adoption and use of RA outside the Medi-care program using case studies in six U.S. health care markets (Baltimore, Seattle, Denver, Cleveland, Phoenix, and Atlanta) as of 2001. We found that for purchasing decisions, RA was used exclusively by public agencies. In the private sector, use of risk adjustment was uncommon and scattered and assumed informal and unexpected forms. The most common private sector use of RA was by health plans, which occasionally employed RA in negotiations with purchasers or to allocate resources internally among providers. The article uses classic technology diffusion theory to explain the adoption and use of RA in these six markets and derives lessons for health policy generally and for the future of RA in particular. For health policy generally, the differing experiences of public and private actors with RA serve as markers of the divergent paths that public and private health care sectors are pursuing with respect to managed care and risk sharing. For the future of RA in particular, its history suggests the need for health service researchers to consider barriers to use adoption and new analytic technologies as they develop them.