Side effects: a dose of competition and access to care

The Federal Trade Commission and Department of Justice 2004 report Improving Health Care: A Dose of Competition argues in favor of increasing competition among health care providers. Several of the proposals within the report, however, may pose risks for access to care. The report urges that the current system of implicit cross-subsidies for indigent care be replaced with insurance expansions that provide coverage to individuals. Such a substitution would certainly enhance access, but would be very costly and likely require considerable government intervention in the health care system. In the absence of a substantial expansion in coverage, reductions in cross-subsidies could limit access to care through the existing safety net. The report argues that insurance mandates limit access to care by driving up cost and reducing choice. In some cases, such as mental health and substance abuse, however, the unregulated market may not cover a benefit at all, leaving people with less coverage and less choice. Finally, the report stresses the importance of linking costs to quality. Such a linkage is likely to lead to a health care system in which poor people obtain poor-quality care at low prices--a result that many would find disturbing.     

Why we must end insurance discrimination against mental health care

In this Policy Essay, Representative Patrick Kennedy argues that insurance discrimination against those suffering from mental illness constitutes a serious and often overlooked deficiency of the modern American health care system. While the Mental Health Parity Act of 1996 was an important step toward resolutions of this issue, many loopholes remain that allow insurance companies to deny much-needed coverage to those suffering from such illnesses. This Essay details how improving access to health insurance for the mentally ill is not only socially beneficial, but also economically sound; the cost of instituting mental health parity is far outweighed by the costs that employers bear because of the reduced productivity of untreated mental illness sufferers. Representative Kennedy recommends that these problems may be addressed by additional mental health policy legislation--specifically, the proposed Paul Wellstone Act.     

Constitutional protection of confessions made by mentally retarded defendants

Criminal confessions made in response to custodial questioning are excluded from evidence unless a defendant voluntarily, knowingly and intelligently waived his Miranda rights. In Connelly, the Supreme Court erred by holding that, absent explicit police coercion, a mentally ill individual's waiver is valid. The Court failed to consider the defendant's subjective impairments that might invalidate his waiver. By contrast, the Patterson Court suggested that a defendant's right to counsel may attach at an early stage in a criminal proceeding if the defendant has a significant need for counsel. This Note addresses the special needs of a mentally retarded person in the criminal justice system. The Note argues that mentally retarded suspects require careful explanation of Miranda rights in order to understand them. The intellectual and adaptive deficiencies which characterize mental retardation also necessitate an inquiry into a valid waiver that accounts for these disabilities. Furthermore, the special needs of the mentally retarded mandate that the right to counsel attach as early as the precustodial stage of an investigation. Early access to counsel most effectively assures that a mentally retarded person's waiver of constitutional rights is voluntary, knowing and intelligent.     

Medicaid rationing in Oregon: political wolf in a philosopher's sheepskin

Although the details of the proposal have shifted since it was first described, the Oregon Medicaid waiver has had one consistent feature: it will reduce benefits to AFDC mothers and children who are currently covered by Medicaid in that state, in the hopes of increasing coverage for other individuals who are now uninsured. Because of the adverse consequences for the AFDC population, there should be strong evidence supporting the purported benefits of the proposal before proceeding with the waiver. One of the most intriguing aspects of the waiver proposal is the claim that the money currently being spent on AFDC beneficiaries could be redistributed to expand coverage to a substantial number of the uninsured. The concept is that far more people could receive the most valuable services if those now being served gave up their coverage of the least valuable services. Other purported benefits of the waiver include enhanced citizen participation in decisionmaking, cost-savings, and improved payment levels and delivery arrangements. Remarkably, this analysis of the proposal reveals that the waiver is likely to achieve none of its stated objectives, and instead will have adverse consequences not identified by its proponents. What the proposal would do is to insulate politicians from visible responsibility for limiting benefits for AFDC children and adults. Finally, the proposal undermines 25 years of Medicaid as an entitlement program. As such, it would establish as a social ethic the principle that the poor can be relegated to inadequate care. Such an extreme measure is not justified by the fiscal situation in Oregon, which is not extraordinarily poor or overtaxed, and does not have a particularly generous or unusually expensive Medicaid program.     

Drug counselling behind the prison wall: staff responses to collaborative challenges

In the last decade, 13 Drug Counselling Units (DCUs) have been established in Norwegian prisons. These units are to offer prisoners with substance use problems coordinated treatment and rehabilitation so they can better cope with their problems during imprisonment and after release. Key means in achieving these goals are to establish inter-agency collaboration between the prison service and the specialist health services. Psychologists, social workers and prison officers from these institutions are to form an inter-professional team in the collaborative process. This study explores the challenges these occupational groups face when they collaborate within this organizational frame. The results show that the occupational groups experience two of the same types of challenges, but that they respond differently to them. The pattern of responses impacts collaboration, both in positive and negative ways. However, all occupational groups endeavour to maintain a high standard within the institutional framework provided by the Norwegian prison system. This article discusses how the responses of the occupational groups in the collaborative processes in the DCUs are influenced by their affiliation to the DCUs, as well as the system of management and professional logic.     

Institutionalized Knowledge Challenges in Pesticide Governance: The End of Knowledge and Beginning of Values in Governing Globalized Environmental Issues

This paper looks at the particular challenges that cross-level interdependence has for the use of knowledge in decision-making for environmental governance. Analytical questions surrounding knowledge generation, use, and flow and the role of institutions in shaping these arise in a multi-level context. By using results from a study on pesticide use in developing countries, some of the particular challenges in relying on scientific knowledge for governance of globalized environmental issues are illustrated. The case involves a situation with significant mismatches between access to and need for knowledge by decision-makers at the different governance levels. The exploration of various strategies to address such mismatches allow discussions not only on the role of knowledge and institutional design but also their limitations and how more inclusive values would serve a system of multilayered governance.     

行贿意愿差异与大湾区廉政合作治理:基于A市与香港的比较研究

粤港澳大湾区各城市在社会环境上的差异,既是廉政建设区域间合作的挑战,也是机遇。在不同的社会背景下,人们对腐败的认知和接受程度不同,这在很大程度上通过行贿意愿的差异呈现。因此,了解社会环境对行贿意愿的影响,不仅有助于制定行之有效的廉政治理策略,也凸显不同地区之间信息交流和治理合作的重要性。那么,在不同的社会场景下,人们的行贿意愿会有怎样的差异?受到哪些社会环境因素的影响?行贿意愿差异的比较研究对廉政合作治理具有什么理论和政策涵义?新制度主义理论为回答这些问题提供了有益的启发。2019年在香港与大湾区A城市所作的问卷调查为不同地区相异的社会条件下的行贿意愿差异提供了分析依据。研究结果表明,在行贿场景所预示的社会条件发生变化时,市民行贿的意愿也随之变化。这种变化受到制度环境因素和社会环境因素两方面的影响。因此,在香港与大湾区其他城市社会条件不尽相同、而经济和社会交往又不断增加的情况下,如何抑制跨境贿赂是廉政合作治理必须面对的重要问题。     

A road map for universal coverage: finding a pass through the financial mountains

Government already pays for more than half of U.S. health care costs, and nearly all universal health insurance proposals assume continued government involvement through tax subsidies and other means. The question of what specific taxes could be used to finance universal coverage is, however, seldom carefully examined, in part due to efforts by health care reform proponents to downplay tax issues. In this article we undertake such an examination. We argue that the challenges of relying on taxes for universal coverage are even greater than is generally appreciated, but that they can nevertheless be met. A proposal to fund a universal health insurance voucher system with a value-added tax illustrates issues that would arise for tax-financed plans in general and provides a broad framework for a bipartisan approach to universal coverage. We discuss significant problems that such an approach would face and suggest solutions. We outline a long-term political and legislative strategy for enacting universal coverage that draws upon precedents set by comparable legislative initiatives, including tax reform and Medicare. The results are an improved understanding of the relationship between systemic health care finance reform and taxation and a politically realistic plan for universal coverage that employs undisguised taxes.     

The mental health service crisis of neoliberalism -- an antipodean perspective

Major transformations in forms of governance of the liberal state have been wrought over the course of the last century, including the rise of neoliberalism and 'new public management.' Mental health too has witnessed change, with pharmacological treatment displacing residential care, a shift to community-based services, mainstreaming with general health care, and greater reliance on civil society institutions such as the family or markets. This article considers whether mental health law, and its court/tribunal 'gatekeepers' have kept pace with those changes. It argues that the focus of the liberal project needs to shift to measures which will better guarantee access to mental health services, and keep a more watchful eye on both 'hidden' coercion of people on community treatment orders, and passive neglect of human need.     

The New Collaborative Environmental Governance: The Localization of Regulation

This article examines the new collaborative environmental governance, an enterprise that involves collaboration between a diversity of private, public, and non-government stakeholders who, acting together towards commonly agreed goals, hope to achieve far more collectively, than individually. Such an approach appears to blur the familiar sharp boundaries that separate 'the state' from civil society, yet we still know very little about exactly what this blurring of public and private adds up to, and what its implications are. This new form of governance is examined through the lens of three Australian case studies. Each of these studies involves participatory dialogue, flexibility, inclusiveness, transparency, institutionalized consensus-building practices, and, at least to some extent, a shift from hierarchy to heterarchy. The paper examines the relationships between new and old governance, the architecture of these new initiatives, the role of the state, and the importance of negotiating in 'the shadow of hierarchy'.     

HIV vaccines: current challenges and future directions

Volume seven of the Review will mark the tenth anniversary of the Canadian HIV/AIDS Legal Network with a series of articles that describe past developments and future directions in several areas of policy and law related to HIV/AIDS. The following article is the first of these, discussing current challenges and future directions in the development of and access to HIV vaccines. It argues that governments are under public health, ethical, and legal obligations to develop and provide access to HIV vaccines. It further explains what is required for governments to fulfill their obligations: additional commitment and resources for HIV vaccine development in the context of increased global research and development regarding diseases of the poor; increased support and advocacy for partnerships to develop HIV vaccines; enhanced regulatory capacity in every country to review, approve, and monitor HIV vaccines; and assurance of global supply of, procurement of, delivery of, and access to vaccines in the context of efforts to increase global access to public health measures and technologies.     

Clustering of Multilateral Environmental Agreements: Potentials and Limitations

The concept of clustering of multilateral environmental agreements (MEAs), i.e. the integration of groups of MEAs or parts thereof, has acquired prominence in recent discussions about reforming international environmental governance. Understood as a continuing process, clustering of MEAs aims at advancing the ongoing process of integrating the elements of this system more systematically and dynamically. This paper proceeds in three steps. First, it demonstrates that a distinction needs to be made between clustering of organisational elements of MEAs and their functions, since the conditions and the effects of their integration differ significantly. Second, it argues that – in contrast to several existing approaches that seek to build clusters starting from similarities in one dimension – any attempt to integrate elements of MEAs needs to be based upon the analysis of a range of factors that influence the prospects of such integration (including overlap of membership and issues, practical feasibility, legal obstacles, and functional requirements). Third, the article contrasts the main potential benefits of a clustering of MEAs, namely efficiency gains and an increase in the coherence of international environmental governance, with the main challenges of international environmental policy, namely reaching agreement, implementing such agreement effectively and preventing/managing inter-institutional conflict. While clustering cannot be expected to make a significant direct contribution to addressing these challenges, it has a potential to economise and enhance the system of international environmental governance with positive indirect effects promoting better international environmental protection in the longer term.     

Prizes for innovation of new medicines and vaccines

This article argues that prizes can help stimulate medical innovation, control costs and ensure greater access to new medicines and vaccines. The authors explore four increasingly ambitious prize options to reward medical innovation, each addressing flaws in the current patent system. The first option promotes innovation through a large prize fund linked to the impact on health outcomes; the second option rewards the sharing of knowledge, data, and technology with open source dividends; the third option awards prizes for interim benchmarks and discrete technical problems; and the final option removes the exclusive right to use patented inventions in upstream research in favor of prizes. The authors conclude that a system of prizes to reward drug development would break the link between R&D incentives and product prices, and that such a reform is needed to improve innovation and access to new medicines and vaccines.     

跨国合作：全球化视阈下食品安全治理的新构想

食品安全是关系到整个人类生存与发展的严峻问题,已成为各国政府和人民共同关注的焦点。经济全球化使得食品安全成为全球性问题,各合作治理主体加强合作,采取协调行动,实施跨国合作治理是解决该世界难题的有效之策。     

The devil is in the details: Managed care and the unforeseen costs of utilization review as a cost containment mechanism

This article addresses issues of liability when a single-payor in a national health care system makes a decision based on a utilization review program that injures the patient as a result. In Part I, the history of Managed Care Organizations (MCOs) is discussed to establish an understanding of the current health care landscape. Part II explains MCOs' use of utilization review to contain costs and analyzes the manner in which courts have addressed the issue of MCO liability for patient injuries sustained from denial ofcoverage. Finally, Part III concludes that current case law may limit a patient's access to a remedy for injuries sustained from a utilization review decision in a single-payor national health care system.     

Towards Institutional Symbiosis: Business and the United Nations in Environmental Governance

This article analyses the potentially symbiotic role of business and the United Nations (UN) in global environmental governance. Contending that a stronger and more coherent UN in the realm of the environment is in the interest of the business community, we focus on three main issues: what the UN needs to become stronger in environmental affairs; what business could provide on this behalf; and how business could benefit from a strengthened UN. We consider the current structural dilemmas of the UN environmental system, including concerns about institutional multiplicity and how these may affect business engagement. After reflecting on perceived and actual challenges and opportunities for business participation, we conclude with three substantive solutions towards more efficient collaboration. These solutions centre on the continuation of an interactive database begun by the Global Environmental Governance Project, a joint initiative of the Yale Center for Environmental Law and Policy and the College of William and Mary.     

协同共治:粤港澳大湾区建设中大学的角色定位及其实现路径

在国家战略背景下,粤港澳大湾区高等教育融合发展问题倍受社会关注。课题组在粤港澳大湾区、旧金山湾区、纽约湾区、波士顿湾区和东京湾区等国际湾区收集了丰富的访谈资料,在一手资料及协同治理理论基础上,采用扎根理论质性研究方法构建起大学在粤港澳大湾区建设中的角色及治理路径模型。研究结果表明,大学在大湾区建设中承载着特殊角色与常态化角色。特殊角色是湾区文化与价值引领;常态化角色包括英才培育、知识创造、成果转化、制度创业等。适应粤港澳大湾区具体情境,实现大学积极治理的主体角色,必须发挥多元主体协同共治的作用,湾区高等教育协同治理路径表现为大学与政府协同、大学与市场协同、大学与社会协同、大学与大学协同以及大学内部治理协同。     

Risk,response, and mental health policy: learning from the experience of the United Kingdom

Policy makers in the United States and the United Kingdom recognize that mentally disordered offenders present special challenges to law enforcement, mental health, and social service systems, as well as the community. Although various policy initiatives have advanced over the past twenty years to improve the management of mentally disordered offenders, mental health policy has chronically failed in both countries. Because safety concerns have emerged as the mental health system has been "deinstitutionalized," debate is growing about whether the community-care approach works-for the community. This study argues that mental health policy fails because policy makers focus on the wrong risks and design policies that manage these risks in ways that increase the possibility of adverse clinical and economic outcomes. The argument made here uses the case of persons with severe mental illness in the United Kingdom as an example of the complex relationship between risk and policy making in democratic governance. Emphasis is on the nature of risk in mental health policy and how government responds to policy and political risks. Mental health policy in Britain is then analyzed in terms of its response to and management of risks. Mental health policy has historically mismanaged the risk issue in the United Kingdom and as such has set in motion the growing community-care backlash. The path to a better outcome lies in the responsible management of the right risks. Lessons from the United Kingdom experience can be usefully applied to mental health issues in many industrial democracies.     

Privatizing Environmental Resources: The Need for Supervision of Clean Development Mechanism Contracts?

This article argues that a current trend in global sustainable development governance is actively to engage the private sector in participating in the process of implementing global and national policy goals. This trend is based on the notion that the private sector has the ideas, technologies and resources at its disposal that can be channelled to addressing global environmental challenges. This new trend does not, however, take into account the past and present implications of private sector investment in fields such as mining and forestry. Nor does it closely examine how private sector rules will subsequently infiltrate and govern environmental management. On the basis of an examination of current policy developments and contracts in the area of environmental management and their implications for developing countries, this article argues in favour of establishing an authority that oversees the legitimacy and legality of these new contracts, especially in, but not limited to, the area of climate change.