Assessing Medicaid managed care in eastern state.

This case examines the expanding role of managed care programs in improving health care for the poor while controlling runaway health care costs. The case asks what the commissioner of health in a large eastern state should do to effectively monitor Medicaid managed care programs in her state. The commissioner faces intense pressures for cost containment and strong, but not universal, support for the managed care solution to health care cost problems. The commissioner is herself concerned that the cost savings attributed to managed care may not be real and that the unintended effects on health care may be adverse. Her immediate challenge is to determine what kinds of data she should require service providers to submit to her agency so that she may effectively monitor managed care programs for health care quality, provide positive feedback to health care providers, and establish politically credible program oversight.     

Public Sector Reform

Reform is never far from the centre of public administration practice and scholarship. In this article Doug McTaggart, the chairman of the Queensland Public Service Commission, and Janine O'Flynn, from the University of Melbourne, explore the challenges of reform and the state of play. McTaggart, who was a commissioner on the Queensland Commission of Audit, sets out the case that business as usual will no longer suffice given the range of challenges faced by governments. He sets out to explain how we ended up in our current state and what needs to happen to repair it, drawing on deep experience in the practice of reform. O'Flynn positions reform as one of the central questions in public administration and management and makes the case for rethinking reform conceptually to drive change in practice. In doing so she points to our weaknesses in determining whether reform fails or succeeds and makes the case that, until we rethink reform, business as usual might be all we end up with. McTaggart and O'Flynn bring together the expertise of practice and academia to bring new insights in this persistent challenge of public administration, and raise a series of questions for debate.     

Medicaid Managed Care for Children with Special Health Care Needs: Examining Legislative and Judicial Constraints on Privatization

Over the past decade, much has been written about the results of reinventing government. Most research has examined the effects of executive or managerial perspectives. Using David Rosenbloom's competing perspectives model, we examine Medicaid managed care programs for children with special health care needs to illustrate the influence of legislative and judicial institutional perspectives on the reinvention movement. Legislative and judicial responses to the reinvention of Medicaid managed care reveal the outer limits of what managed care and related executive reforms can accomplish in a Constitutional system that is based on checks and balances among competing institutional perspectives. Furthermore, relative to Medicaid managed care, legislative and judicial responses conserve public responsibility to society's most vulnerable populations. In the long run, the balance of institutional perspectives and values—not managerial innovation per se—will influence public administration.     

THE STATES' ROLE IN HEALTH CARE COST CONTAINMENT*

Under the Social Security Act of 1935, the federal government expanded its involvement in maternal and child health care programs through grants-in-aid to state and local health departments. The Medicaid legislation of 1965 vastly enlarged federal expenditures, and state responsibilities. State performance was frequently criticized, especially in health care cost containment. Recently, the states have initiated several efforts to link cost containment and the quality of health care.     

Health-Care Reform, Managed Competition, and Subnational Politics

"Managed competition" is Congress' likely response to health-carereform. At the center of managed competition are regional healthinsurance cooperatives or alliances. In some states, these allianceswill face daunting numbers of uninsured and underinsured peopleand a hostile reception from business leaders and state governmentofficials. In other states, alliances may be welcomed as a logicalextension of current efforts to expand access to health care.Uneven support for alliances among the states will affect theimplementation of reform, as is typically the case in federallyorganized programs. However, the visibility, power, and financialresources of alliances will also affect state governments. Henceforth,American federalism may include three centers of power, notjust two, and the impact on state politics could be profound.     

Individual integrity,freedom of association and religious exemption

ABSTRACT

Of the many questions Cécile Laborde addresses in her magisterial Liberalism’s Religion, several relate to what she describes as ‘the puzzle of exemptions’. I examine some of the issues raised by her efforts to solve that puzzle: whether her ideal of moral integrity squares with the nature of religious belief; whether we should find the case for collective religious exemptions in freedom of association and the ‘coherence interests’ of associations; how much significance we should give to the ‘competence interests’ of organised religions; and by which criteria we should assess individual claims to religious exemption.     

Systems Ideologies and Street-Level Bureaucrats: Policy Change and Perceptions of Quality in a Behavioral Health Care System

This article examines the stability of street-level bureaucrats' negative perceptions regarding a newly implemented managed care system on quality of care and service delivery in a publicly funded behavioral health care system. Overall findings indicate that the generally negative perception of managed care did not differ between staff in the two programs, indicating a weak effect on attitudes of frontline workers. More proximal variables to the caregiver, such as service type and job title, show more influence on attitudes. The conclusion discusses the implications of these findings for practicing administrators and academic researchers.     

State health reform: Effects on labor markets and economic activity

Individual states are actively weighing health care reform proposals and their potential impacts on many levels, including states' own economies. This article considers the effects on state economies of two instruments of health reform: employer mandates and cost containment. The literature suggests that an employer mandate will reduce employees' wages in the long run. In the short run, however, to compensate for the costs associated with mandated health care insurance for their employees, firms may raise their prices to consumers, reduce the number of employees or allow a drop in profit margins. By increasing health care spending and the number of insured persons, mandates would also increase states' levels of economic activity. Though cost containment may dampen the stimulative effects of expanded coverage, resources not spent on health care as a result of effective cost containment might be redistributed to other sectors in a state's economy.     

THE AFFORDABLE CARE ACT'S EFFECTS ON PATIENTS,PROVIDERS, AND THE ECONOMY: WHAT WE'VE LEARNED SO FAR

As we approach the tenth anniversary of the passage of the Affordable Care Act, it is important to reflect on what has been learned about the impacts of this major reform. In this paper, we review the literature on the impacts of the ACA on patients, providers, and the economy. We find strong evidence that the ACA's provisions have increased insurance coverage. There is also a clearly positive effect on access to and consumption of health care, with suggestive but more limited evidence on improved health outcomes. There is no evidence of significant reductions in provider access, changes in labor supply, or increased budgetary pressures on state governments, and the law's total federal cost through 2018 has been less than predicted. We conclude by describing key policy implications and future areas for research.     

EC Credit Assistance Programs in the Light of the US Experience: Budgetary, Financial and Political Aspects

The bulk of the subsidy cost of European Communities (EC) credit programs is not represented in the EC budget. The cost of EC loans and guarantees are not shown, and only token entries are included for the possible activation of guarantees connected to borrowing and lending. Only in the case of credit programs which entail an interest-rate subsidy, does the budget show an amount corresponding to the subsidy cost. EC budgeting and accounting methods, like those in most member states, hide the full cost of the EC credit programs. The lack of subsidy disclosure has political implications in terms of budget decision-making and control; budget authorities have neither adequate information to compare the trade-offs among the various credit assistance programs and other expenditure programs, nor to evaluate or measure the efficiency and effectiveness of credit operations. Moreover, the citizens of Europe, who are taxpayers both in their states and, to a lesser extent, in the Community, do not have a clear understanding of the costs and benefits of credit programs, either at the state or the EC level. The article refers to the US experience of federal credit reform, especially with regard to the disclosure of the cost of credit programs, as a good example of budget transparency and investigates to what extent this experience could be applied to the European Communities.     

The tripartite regulation of America's health services

The Republican takeover of Congress suggests that the payer-driven forces of managed care, capitated payment, and the regional networks (alliances) will serve as centerpieces to improve the organization, financing, and delivery of our nation's health services. These "voluntary" alliances, frequently as an amalgamation of health providers and health insurance underwriters, often foreshadow the powerful, geographically linked regional health networks that are evolving into oligopolies. The authors anticipate, as a result, the formation of state health services commissions that will regulate market share, the scope of health services, reimbursement rates and allowable profits. State departments of public health and insurance will have their own regulatory duties. Complex relationships will result as these groups will often have conflicting, politically-charged goals.     

Managed Care in the USA: origins,HMO strategies and the marketing of health services

• HMOs appeared in the 1970s in a context of increasing health‐care expenditure. These organizations now provide care to an increasing share of the general population, offering cost/effectiveness studies and sophisticated cost‐control mechanisms directed at care providers and patients. The following article reviews the history of Managed Care organizations, details the service they offer, discusses the current difficulties that have forced them to withdraw from some market segments and considers what prompted the government to intervene to protect patients' interests. The paper also describes the growing hostility of patients and physicians to Managed Care.

Copyright © 2007 John Wiley & Sons, Ltd.     

MANAGED COMPETITION IN FLORIDA HEALTH CARE: ITS STRENGTHS AND WEAKNESSES

Managed competition in health care is a model for reform that has been adopted by several states and considered as a model for national health care reform. This article assesses the strengths and weaknesses of managed competition in Florida based on the responses of essential participants in the managed competition network and data from network documents. Results of the analysis reveal that the strength of the reform has been in offering small employers and their employees a wide choice of health care insurance and in providing them with information to make informed health insurance choices. In addition to increasing choice and information, the managed competition network has become the small group insurance industry watchdog, applying pressure to keep the market fair and functioning. However, cost control difficulties and a continued limited access to health insurance demonstrate the weaknesses of the Florida reform. The article concludes by discussing the politicization of health care reform in Florida and the future of this reform effort in a changing political climate.     

Austerity Regimes at the Local Level: Examining Fiscal Effects of Austerity Commissioners Using a Time-Series Synthetic Control Method

Abstract

From a democratic perspective, the replacement of government or parliament by a public manager to enforce budget discipline marks a serious intervention. Transferred to the local level, the replacement of the mayor and the council in three German municipalities by a state official (a so-called state commissioner) in recent years has raised questions about the legitimacy and adequacy of such a strong interventionist instrument. One crucial answer to be given to this legitimacy issue concerns effectiveness, in other words whether the instrument can fulfill its designated task by improving the local fiscal situation since the fiscal success of the commissioner is a basic prerequisite for legitimacy. By using a time-series approach of the synthetic control method (SCM) and constructing a synthetic comparison case to the town of Altena, an answer regarding the commissioner’s potential to reduce the short-term debt can be given. The commissioner was successful in limiting the debt increase and seems to have reversed the debt trend. This finding supports the effectiveness of rather hierarchical instruments for ensuring fiscal discipline at the local level and thereby adds to broadening the international public management literature on municipal takeovers.     

The State of American Federalism, 1997 - 1998

Although it was a relatively quiet year for the courts and congressionalaction, 1997–1998 saw several developments that may significantlydefine federalism in the coming years. The 1998 federal budgetis projected to show a surplus, ending decades of deficit financinginWashington, D.C., but also raising questions about the budget'sfiscal impact on federalism and intergovernmental relations.Devolution took a back seat in Washington, D.C., as concernsabout managed care, education, and internet access led to proposalsfor increased federal involvement in state and local affairs.The states continued their implementation of welfare reformand launched other programs in health, environment.     

Social Rights,Civil Rights,and Health Reform in Canada

This article challenges the conventional wisdom that health programs have been largely insulated from welfare state retrenchment. Health care entitlements have in fact been transformed and diminished, albeit in more subtle ways. Employing rhetorical discursive constructions about the nature of social rights, and capitalizing on passive policy drift, reformists have succeeded in altering the right to health care away from a set of collective obligations and toward the competing claims of individuals. As a result, public health insurance programs are abandoning universalistic principles in favor of a narrower conception of rights that is consistent with and supportive of increased privatization of health care financing. Discursive constructions aimed at persuading target audiences to change their ideas aid and abet systemic and institutional factors, making policy changes seem both necessary and inevitable. Using the case of Canada, I contend that such changes are a form of retrenchment.     

Pauline Hanson and the Rise and Fall of the Radical Right in Australia

Abstract

In this paper Deutchman examines the rise and fall of the radical right in the late 1990s in Australia. In particular, she focuses on the rise and fall of Pauline Hanson's One Nation party. In 1996 an obscure backbencher named Pauline Hanson was elected to the federal parliament. From the moment she made her first speech in September of that year she was rarely off the nation's front pages. By April 1997 she started her own political party, One Nation. By July 1998 her party was able to win an astonishing 23 per cent of the vote in the Queensland state election. And by October 1998 she lost her own seat in Parliament and saw her party's fortunes decline. Deutchman examines various theories which have attempted to explain the rise of radical-right parties in Europe and the United States in order to understand the Australian case. Notably, she argues that the convergence of the two major parties, the Coalition and the Australian Labor Party, provides the setting in which the emergence of a radical-right party becomes more likely. Such a party often emerges when the two major parties are centre-right ones, as is the case in Australia. In most countries research has shown that it is difficult for a radical-right party to do well nationally. Indeed, this has been true in Australia. Despite the fact that One Nation has lost much of its electoral support, Deutchman argues that it is premature to write off the radical right in Australia.     

Variation of employee benefit costs by age

Health care, pension, and disability plans account for the bulk of employers' benefit costs, as defined in this article. Because those costs tend to rise as employees get older, the age structure of the workforce affects not only employers' costs but ultimately their competitiveness in global markets. How much costs vary depends in large part on the structure of the benefits package provided. The method a company chooses to finance benefits generally varies with its size. This article focuses primarily on the benefit practices of large, private employers. In the long run, such employers pay the costs associated with the demographics of their workers, whereas small employers can often pool costs with other companies in the community. In addition, small employers often offer fewer benefits, and the costs and financing of those benefits are subject to the insurance markets and state regulations. The discussion of benefit packages is illustrated by case studies based on benefits that are typical for three types of organizations--a large traditional company such as steel, automobile, and manufacturing; a large financial services company such as a bank or health care organization; and a medium-sized retail organization. The case studies demonstrate the extent to which the costs of typical packages vary and reveal that employers differ radically in the incentives they offer employees to retire at a specific time. An employer can shift the variation in cost by age by changing the structure of the benefit program. The major forces that drive age differences in benefit costs are the time value of money (the period of time available to earn investment income and the operation of compound interest) and rates of health care use, disability, and death. Those forces apply universally, in the United States and elsewhere, and they have not changed in recent years. However, the marketplace and the prevalence of various types of benefit programs have changed, and those changes have generally resulted in less cost variation by age and more frequent employer selection of benefit packages that exhibit less variation by age.     

Health Care Reform in Britain and Germany: Recasting the Political Bargain with the Medical Profession

Health care systems in the postwar period have been governed by political bargains between the state and the medical profession that have delinzated their respective powers and jurisdictions. Recent health care cost containment reforms in Britain and Germany are altering these bargains, and thereby challenge the prerogatives and autonomy of the medical profession in health policy formulation and in administration of the health care systems. But these challenges to doctors' power and autonomy vary between the two countries. Britain's 1989 “internal market” reforms attack the corporatist bargain with physicians by introducing market mechanisms into the National Health Service and, at the same time, strengthening central state control of the health care system. In Germany, on the other hand, the government's 1992 reforms only partially breached the corporatist bargain with doctors in order to strengthen rather than destroy this governance arrangement. The government has tried to curb what it views as excessive power of doctors while still allowing them a significant degree of corporatist self-governance. The reform efforts in both countries highlight some of the problems with different governance arrangements in health care systems and, more specifically, the difficulties associated with a market in health care.     

家庭、国家与儿童福利供给

儿童抚育事务在传统上主要由家庭承担。工业革命之后,西方国家才开始系统关注并发展儿童社会福利,为抚育儿童的父母提供制度化的国家支持,并对父母亲权的实践进行国家监督。尽管不同的儿童社会福利理论对于如何界定家庭与国家在儿童抚育与儿童福利供给过程中的关系模式存有分歧,但是,关注得不到家庭适当抚育的儿童的福利,并为其提供必要的福利服务,已经成为现代国家的共识。鉴于我国传统的以家庭为主的儿童抚育模式出现失灵,积极发展选择性的儿童福利服务具有其充分的合理性。