THE ENTERPRISE FORMULA,NEW PUBLIC MANAGEMENT AND THE ITALIAN HEALTH CARE SYSTEM: REMEDY OR CONTAGION?

Health care services represent an extraordinary experimental ground for introducing wider political and institutional transformations of the state. The adoption of entrepreneurialism into European health care systems has strengthened technocratic decision making over traditional mechanisms of political control. In Italy, in the midst of a severe legitimacy crisis affecting the administrative and political systems at the beginning of the 1990s, New Public Management ideas seemed ‘the’ remedy against the pathological politicization of distributive politics. Much hope has been placed since in a new and ascending group of general managers, entrusted with the ambitious mission of running health care services more efficiently and with the unenviable expectation of resuscitating public trust in welfare institutions. By analysing the 1992 Amato government’s landmark health care reform in its substantive changes, this paper explores the last decade’s main reform trajectories of Italian health care reforms that irreversibly transformed its institutional arrangements and organizational structure, namely the enterprise formula and the regionalization of the health care sector. The paper suggests that the political turmoil of 1992–94 served as catalyst for radical policy change and argues that the single most important explanation for the enactment of New Public Management‐type reforms rests in a new executive reinterpretation of its legislative prerogatives and function.     

Something Must be Done-Military Intervention

In the late twentieth century, the United States' federal government responded to the threat of terrorism by passing a wide range of counterterrorist laws. The vigor that accompanied these initiatives echoed at a state level where, virtually unnoticed, states passed similar legislation. This article examines state measures in three areas: the funding of foreign terrorist organizations, the use or threatened use of weapons of mass destruction, and definitions of terrorist activity. While these statutes, as a legal matter, may not violate any specific federal provisions or constitutional prohibitions, they raise important questions about federal supremacy in foreign affairs and the constitutional protections afforded citizens. More significantly, as a policy concern, these provisions threaten America's ability to speak in one voice, introducing divisions into the domestic realm and diminishing the ability of the federal government to negotiate with foreign states and organizations. They also mask an appropriate role for the states in fighting terrorism. Both the policy implications and legal considerations suggest that such measures may ultimately undermine America's ability to counter the terrorist threat.     

Changing Patterns of Privatization: Ideology,Economic Necessity,or Political Opportunism

This article considers privatization decisions by governments in four Australian states over twenty years of micro-economic reform. It focuses on the policy frameworks and political context for privatizing government enterprises, drawing on Kingdon's framework for policy change to analyze differences in the substance and timing of decisions. In the 1990s, governments considered privatization as an economic and political strategy to resolve the problem of state-level fiscal crises, but the patterns of adoption were variable. Two states resisted the general trend toward privatization, but recently changed their position. We argue that the recent financial crisis provided a window for reintroducing contentious reform initiatives that had lost momentum.     

Back to the future: Polish health care reform

In January 1999, the Polish government implemented a new law reorganizing the health care in the country. This paper includes an outline of the changes, the main impact of which consisted of introduction of universal health insurance administered by Health Insurance Funds (“Kasy Chorych”). In June 2001 and 2002, a survey of insurance administrators and health care workers provided data concerning the reception of the new system, the perceived inadequacies, and the postulated changes. The intended objective of privatization of health provisions appears as remote as it was before the changes. The major obstacles are identified as political hurdles, physician resistance, and continued dependence on state allocations.     

Evaluation of the south carolina comr/cunity long-term care medicaid waiver for the elderly and disabled

Medicaid waivers play an important role in the health policy process. Various health care policy initiatives have encouraged states to experiment ith their Medicaid programs by expanding coverage to populations not traditionally covered by Medicaid, or by delivering Medicaid services in non traditional ways. Lessons learned by individual states' Medicaid waivers could be an important part of the health care reform debate. This paper presents an evaluation of a Medicaid waiver operating in South I Carolina. The South Carolina Community Long-term Care Waiver for the Elderly and Disabled is evaluated for cost effectiveness, quality of care, and client satisfaction. This evaluation shows that the waiver is highly effective in offering individuals who are medically and financially eligible for Medicaid supported nursing home care a viable, cost effective, high quality alternate to institutionalization.     

Health care reform in Israel: An historical and sociopolitical conundrum

A new and comprehensive National Health Insurance Law was implemented in Israel on January 1, 1995. This major health care reform initiative culminated an effort lasting several decades to assure broad universal health care coverage for the population as a matter of national law. Issues that affected the development of the reform package included 1) the formation of sick funds that provide care to over 96% of the population as part of other powerful sociopolitical organizations, 2) the historical development of parallel private July 16, 1995 and governmental health care systems before Israel became a state in 1948 and the post-state maintenance of multiple health care delivery systems, and 3) the close interactions of health care systems and the political processes and parties of the nation. This paper describes the effects of these forces on resisting changes that were widely accepted as being necessary to expand access, control rising health care costs, and improve the efficiency of the nation's health care system.     

Health care finance in the US: Past,present, and future

Presently the US is the only major industrialized nation that does not insure universal access to health care for all of its citizens. Although the US spends one out of every eight dollars on health care, over one-eighth of all Americans lack basic health insurance coverage. Another concern is health care cost inflation. The quest for comprehensive health care coverage for all Americans began shortly after the turn of the century and has received varying degrees of support since then. Since the historical course of health policy in the US has followed an evolutionary rather than revolutionary course, unless consistent policies are developed to rationalize the incentives facing consumers, providers, and insurers, alike, the future path of American health policy will continue to be characterized by disjointed incrementalism. National health insurance can provide decision makers with a tool to structure and focus the American health care system. In order for cost control measures to be effective they must be coordinated with measures to promote universal access, and vice versa. NHI can be a catalyst to focus attention on the dual goals of access to care and cost containment.     

Professionalizing the american states in the 1990s

This article reviews state executive branch efforts to professionalize in the 1990s. The states’ political, fiscal, and managerial capabilities are assessed by examining recent changes in governors’ offices, executive branch reorganizations, and management and productivity initiatives. The focus is on the process used to better prepare the states to respond to change, the multi-agency issues under reform, and the relative lack of integration of state agency reform with local government change. The analysis is based on research conducted by the author in 1991.     

The oregon plan: Toward a model for the future of health care financing

The State of Oregon has proposed a new method of financing health care services for its citizens. Oregon proposes to fund only the most cost-effective services. But in addition to narrowing the offering of health services funded by the State, Oregon proposes to fund all of the State's poor for services, no matter the family status. This broadened number of poor (everyone at the federal poverty level and below, single or married, children or not) will provide health care for more than 200,000 additional Oregonians. The supplementary legislation, SB 534 and SB 935, combined with broadened health care coverage for the poor (SB 27) will cover an additional 478,000 Oregonians. Nearly 95 % of its citizens will have some form of health insurance in Oregon.     

Developments in health care finance

Costs, quality, and access are the central themes in health care policy in the United States. In the 1980s the predominate issue is becoming access, and the likelihood for universal health coverage, or a national health insurance program, is growing. This paper explores how the America health care system got to this point and examines the present conditions, the trends, and the consequences of those trends.     

Restraining mandated service costs: Innovative diffusion of transplant technologies in arizona's medicaid program

Medical technological innovations while usually beneficial are inevitably costly to the medical profession, to government, to the economy, and to society in general. Organ transplantations are prime examples of this dilemma. Such services are mandated by the federal government to state Medicaid programs. A cost-saving effort in Arizona's Medicaid program involving negotiation and competitive bidding with providers of transplantation services could have broad positive implications for states willing to copy Arizona's approach. The approach may even have implications for general health care reform.     

PUBLIC RESPONSIBILITY AND INEQUALITY IN HEALTH INSURANCE COVERAGE: AN EXAMINATION OF AMERICAN STATE HEALTH CARE SYSTEMS

This article examines the effect of the three publicness dimensions on inequality in health insurance coverage across 50 American state‐level health care systems. The analysis validates a Gini‐coefficient measure of Americans' unequal distribution of health insurance coverage across nine income groups and compares public ownership, financing, and control of health care systems across all 50 states from 2002 to 2010. There is a significant and negative relationship between public ownership and inequality in health insurance coverage, although the substantive impact of ownership is relatively small. Both public financing and control substantially reduce inequality in health insurance coverage across income groups. However, both of these must be present in order to be effective at reducing inequality. This article expands our understanding of the link between different institutional arrangements and inequality in health insurance coverage in hybrid health care systems.     

Adapting to democracy: Societal mobilization and social policy in Taiwan and South Korea

Democratic transition and institutional change do not necessarily guarantee greater political inclusion, particularly when it comes to the policy influence of civil society groups. Rather, political inclusiveness requires strategic adaptation among societal actors. Actors need to seize upon opportunities endemic to political change. This article provides a comparative analysis of health care reform in democratizing Taiwan and South Korea, focusing on two social movement coalitions, the National Health Insurance Coalition in Taiwan and Korea's Health Solidarity. Both movement coalitions were critical in shaping welfare reform trajectories in Taiwan and South Korea during the late 1990s, despite having been shut out from earlier episodes of health care reform. I argue that these groups (1) strategically adjusted their mobilization strategies to fit specific political and policy contexts, (2) benefited from broad-based coalition building, and (3) effectively framed the issue of social welfare in ways that gained these movements ideational leverage, which was particularly significant given the marginal place of leftist ideas in the postwar East Asian developmental state model. Joseph Wong is assistant professor of political science at the University of Toronto. He is the author ofHealthy Democracies: Welfare Politics in Taiwan and South Korea, published by Cornell University Press. Wong received his Ph.D. from the University of Wisconsin-Madison. The author thanks Edward Friedman, Jay Krishnan, Ito Peng, Richard Sandbrook, Linda White, along with the three anonymous reviewers for their helpful comments on earlier drafts of this paper. Thanks also to Uyen Quach and Nina Mansoori for their research assistance.     

The myth of equilibrium: winner power, fiscal crisis and Russian economic reform

It has become common to describe Russia as a state that has only achieved partial reform due to the influence of powerful economic forces, the ‘winners’ of economic reform, and to assume that the Russian state lacks autonomy. This paper questions how far reform in Russia has been compromised by the power of winners. The failure of economic reform between 1992 and 1998 is explained as a policy response by state officials unable to manage tendencies towards fiscal crisis because of the state's general helplessness in managing the Russian economy, rather than as a surrender of sovereignty to economic interests.     

Reinventing Human Resource Development: Unintended Consequences of Clinton Administration Reforms

Abstract

Many Clinton–Gore government reform initiatives focused on federal training. The reforms were intended to make training a more flexible management tool and give line managers more authority for employee development and training. Under political directives, a number of changes were undertaken simultaneously without adequate monitoring to evaluate their impact on agency performance. Many changes had unintended, negative consequences. When reinvention efforts ended in 2000, federal training programs did not work better and cost less and, in fact, the opposite was true and many problems remained unsolved.     

REINVENTING THE AMERICAN FEDERAL GOVERNMENT: REFORM REDUX OR REAL CHANGE?

Reinventing government in the United States is the most recent of several efforts to reform public organizations and management. A cornerstone of the Clinton Administration's agenda for change, reinvention is proceeding on several levels. One is that of political symbolism and rhetoric: reduce waste, eliminate unnecessary programmes, and improve efficiency. Another level is found in the reinvention laboratories created throughout the federal government. Here the focus is on quality, customer service, streamlining processes and procedures, and eliminating unnecessary rules and regulations. A third level is found in policy and system changes; here the emphasis is on examining broad functions, decentralizing major activities, and providing legislative support for necessary changes.
Implementation of reinvention activities has been decentralized and loosely monitored. Many of the initiatives in the reinvention laboratories are difficult to track and analyse; changes at this level do appear, however, to be extensive and diverse. Broader legislative changes have not been so extensive and the Clinton Administration has been slow to introduce key legislative packages. The role of Congress is unclear.
Despite uneven progress and failure to ask key policy and implementation questions, reinvention is creating significant change in the federal government. The outcome of those changes and the long-term future of reinvention depend on the continued commitment of the members of the public service, as well as much clearer political support and will.     

Financing the health care of the aged.

The Medicare and Medicaid programs, which were enacted through the 1965 amendments to the Social Security Act, placed the federal government in the central role of assuring access of the aged and the poor to needed medical care. In this article the trends in the sources of financing medical care services for the aged are examined. The distinction in terms of insurance coverage between acute care services and long-term care services is highlighted. The effect of the programs in terms of reducing the aged's direct financial cost of medical care, increasing their access to medical services, and improving their health status is explored. The unanticipated increase in the cost of these programs has led to a change in emphasis in public policy, from assuring access to mainstream medical care to containing the cost of providing care. The direction of new federal policies is analyzed, and it is concluded that no longer will it follow the private sector's specifications of the conditions and arrangements under which health services are provided to program beneficiaries.     

The Civil Servant as Legislator: Law Making in British Administration

How are government policy commitments converted into legislation and what happens in the conversion? The role of civil servants in preparing legislation is far more important than is generally assumed. By looking at the work of four recent bill  teams in Britain – teams of civil servants given the task of developing Acts of Parliament – their crucial roles in initiating policies, placing them on the political agenda (even helping secure their place in a party manifesto), developing them, making sure they pass through parliament and enacting them once they have reached the statute books are assessed. The article explores the composition and working methods of bill teams. These teams work with considerable autonomy in developing legislation, but it cannot be assumed that they operate outside ministerial control. Teams see themselves as reflecting the priorities of the government in general and their ministers in particular. Yet ministers typically know relatively little about the law they are bringing in until they receive the submissions and briefings from their officials. Perhaps the biggest danger for democracy is not a civil service putting forward proposals which a minister feels forced to accept, but rather that ministers do not notice or fully appreciate what is being proposed in their name despite having the political authority to change it and a civil service which bends over backwards to consult and accommodate them.     

Constructing Policy Networks: Social Assistance Reform in the Czech Republic

Abstract

Czech social insurance and family transfers experienced fundamental reform in 1995 but Czech social assistance benefits still lack comprehensive change. This article explains the delay in Czech social assistance reform by appling policy network studies in a postcommunist context. Although few organizations perticipate in the Czech social assistance policy network, they are divided: they lack the common interests and exchangable resources necessary to create dialogue and compromise. The organizations of disabled citizens are the only interest group active in the policy network, with the operators of state social care institutions their primary opponents. In the late 1990s, this already fragmented issue network suffered further division when the EU entered as a powerful network actor with another set of policy goals. Until the policy network structure facilitates more dialogue and consensus‐building, hopes for comprehensive social assistance reform will linger unfulfilled.