Health care for the poor.

In the 1980s the convergence of a number of factors is causing government at all levels, industry, and labor to plan or initiate major reductions in health spending. Important among these are rising health care costs, a troubled national economy, mounting federal deficits and state revenue shortfalls, and the philosophical course and domestic policy of the Reagan administration. In this context government has been rethinking its capacity to finance health services for the poor, and new and sometimes controversial arrangements for delivering these services are being developed. The dilemma government officials face now is how to cut costs while still assuring that quality medical services are available. This article focuses on what these new policy developments and arrangements are and whether the significant gains in access and in health achieved over the past 20 years will be sustained. Because truly sweeping reforms are unlikely, whether government will maintain earlier commitments and established arrangements for financing and delivering health services to the poor will be worked out piecemeal over the next several years.     

Health care and the elderly.

Western values have long emphasized an interventionist approach to problems of health and health care. Yet, as medical technology becomes increasingly expensive and as the number of older people grows, proposed changes often are now governed more by considerations of cost than by quality of services. This tension between cost and quality also affects public willingness to invest in social components of health care despite their importance in enhancing quality of life. The tension emerges in sharpest contrast as scarce resources are allocated by gatekeepers in health maintenance organizations and in the arrangements for long-term care. With respect to financing, what seems to be needed is a creative mix of voluntary inputs from the community, private initiatives, and new programs of public entitlements. With respect to quality of care, what has often been overlooked is the recognition that gains in the quality of life require programs that encourage older people's continued involvement and participation in social life and in active and healthy life-styles. This article discusses the evolving balance between these two types of interventions: the medical and the social.     

Health care reform content and process:propositions from the states

Health care reform and cost containment have become central campaign and policy issues in the United States. Although focus now centers on federal health care reform policy, state governments have been actively introducing health care reform legislation. Some of the health care reform initiatives on the state level have influenced deliberations on the federal level and President Clinton's health care reform initiatives will spur further state experimentation regardless of legislative success in Congress, In 1992 nearly all 50 states had either legislation introduced, or special task forces assigned that addressed health care reform issues. This exploratory research compares the content and process of health reform in four states that attempted major reform in 1992—Florida, Washington, Michigan, and Wisconsin—and draws propositions for state reform based on comparisons of content and process. The four states chosen represent geographic diversity and a balance between legislation seeking partial change and legislation calling for universal health care reform. The principal reform bills in each state are compared and assessed on the degree to which they address eight reform elements; high tech medicine, administration, tort reform, long-term care, regulation, insurance mandates, small business insurance, and insurance portability. These initiatives are also compared on a series of reform process variables that relate to the political process for adopting reform: degree of health sector support, type of political strategy used, reform champion, degree of cooperation among policy stakeholders, and timing of initiative. Based on these four cases the phased/partial approach seems to have a greater chance for legislative success than immediate universal reform. Florida's partial, consensus-building approach resulted in the only signed bill of the four states. Washington's bill, which also took a partial approach, passed the state senate before ultimate defeat in 1992 and eventual passage in 1993. Neither of the more ambitious universal health care reform packages introduced in Wisconsin or Michigan got out of committee. Although some of the plans were thorough, none adequately addressed the tradeoff between increasing access to care and containing costs. In addition, this study will demonstrate that universal health care legislation, does not necessarily equate to comprehensive health care reform. The propositions derived from this research have implications for future state health care reform efforts, as well as for federal health care reform policy in terms of the substantive content of reform proposals and the political process by which they are advanced.     

Health care and AIDS

The acquired immune deficiency syndrome (AIDS) is a harbinger for change in health care. There are many powerful forces poised to transform the industrialized health care structure of the twentieth century, and AIDS may act as either a catalyst or an amplifier for these forces. AIDS could, for example, swamp local resources and thereby help trigger national reform in a health care system that has already lost public confidence. AIDS can also hasten the paradigm shift that is occurring throughout health care. Many of the choices society will confront when dealing with AIDS carry implications beyond health care. Information about who has the disease, for example, already pits traditional individual rights against group interests. Future information systems could make discrimination based upon medical records a nightmare for a growing number of individuals. Yet these systems also offer the hope of accelerated progress against not only AIDS but other major health threats as well. The policy choices that will define society's response to AIDS can best be made in the context of a clearly articulated vision of a society that reflects our deepest values.     

Health care technology assessment: A policy planning tool

Health care technology has developed more rapidly than have the tools to aid decisions regarding that technology's assessment, acquisition and allocation. This article proposes theoretical and technological bases for formulating and analyzing policies for technology assessment. A computerized procedure for measurement and reporting of judgmental sources of technology assessment is presented, accompanied by a pilot study illustrating how the procedure can be used for both research and practical applications.     

Health care policy: lessons from the past and issues of the future

Liberal distributional values, the increasingly powerful capacity of medicine to provide more and better care, and concern about the health hazards of an industrial society fueled the vast expansion of the health care sector during the last 20 years. That growth was facilitated by a growing economy. The current health policy debate at one level reexamines the distributional bases of entitlement programs, and at another seeks alternative resource allocation mechanisms to reduce the cost of health care. This article has two themes. First, distributional and allocational policies are shown to be intrinsically related, so that the health policy debate is fundamentally a clash between liberal and libertarian values. Second, the inexorable social forces driving the health care system are shown to be the aging of the population and the rapid expansion of technology. The resulting dynamics imply the further growth of the health sector, now in the environment of a sluggish economy. Future policies will have to struggle with how to ration scarce health resources and how to reorient the health care sector to the problems of the aged.     

Introduction: the politics of public justification

ABSTRACT

Introducing the special issue, this introduction sketches a broad frame for studying public justification. Addressing the relevance of studying this phenomenon, we contend that justificatory processes are very much at the core today’s politics. Defining the concept inclusively, we highlight the relevance of communicative agency and, at the same time, the salience of communicative contexts that enable this agency. Casting our net widely, we show how public justification is related to other, more thoroughly studied concepts, such as legitimacy, authority and power. Encouraging students of public justification to add to our understanding of justificatory processes, we highlight multiple fruitful methodological avenues for studying the concept.     

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.     

Health care cost escalation in the united states: Implications of market failure

Much of the rhetoric in the debate over health care reform suggests reconfiguring the health care system so that the free market forces can work efficiently. This paper will show that hopes for a free market solution to the maldistribution of health care are false. The free market system cannot work at the same level of efficiency for health care as it does in the distribution of other goods and services. Health care presents an anomaly to the free market system, making optimal and efficient distribution virtually impossible. That failure of the market system has led to a crisis of disparity in health care access and delivery in the United States.     

Introduction: Contemporary Romanian politics

Romania is an archetypical case of protracted post-communism. Its regime transition was problematic and its founding election flawed, allowing successor communists to secure their hold on power. A period of quasi-authoritarianism and failed reform followed until critical elections in 1996 brought the liberal opposition to power for the first time. Since that time its political system has stabilized into a pattern in which electoral competition occurs but political accountability is limited and corruption is widespread. The current regime should therefore be considered as consolidated, bearing the marks of the transition period, but unlikely to undergo any further near term dramatic change.     

Health facility characteristics and the decision to seek care

Utilisation of healthcare facilities is low in many developing areas. One possible explanation is that treatment costs, in time or money, are high. Another is that parents perceive treatment benefits to be low. We combine Philippines DHS data with a subsequent facilities survey in order to examine these issues with respect to treatment for respiratory infections and diarrhoea in young children. Controlling statistically for the selectivity of the initiating illness, we find that the staffing level of nearby health facilities is a determinant of the probability that parents take their ill children for curative care.     

Critical Review: the politics of sovereign debt

In this article, I interrogate what is meant by ‘the politics of sovereign debt’, and examine how various authors, especially David Graeber, have addressed this question. More specifically, I seek to extend my contribution to the goals of the ‘Repoliticizing Debt’ workshop, which inspired this special issue, by proposing a theoretical framework for understanding the role of sovereign debt in mediating the contradictions of neoliberal capitalism, and by challenging dominant treatments of the sovereign debt crisis currently underway in Greece. I argue that the existing literature fails to help grasp the complexity of sovereign debt as a social relation, and that debt must be understood as what Marx refers to as ‘fictitious capital’, that is, capital backed not by a commodity transaction, but by a claim on future value. The management of confidence in the value of fictitious capital through the use of the ‘golden noose’ of debt is the key process to be understood in order to grasp the complexity of sovereign debt crises.