Obesity, courts, and the new politics of public health

Health care politics are changing. They increasingly focus not on avowedly public projects (such as building the health care infrastructure) but on regulating private behavior. Examples include tobacco, obesity, abortion, drug abuse, the right to die, and even a patient's relationship with his or her managed care organization. Regulating private behavior introduces a distinctive policy process; it alters the way we introduce (or frame) political issues and shifts many important decisions from the legislatures to the courts. In this article, we illustrate the politics of private regulation by following a dramatic case, obesity, through the political process. We describe how obesity evolved from a private matter to a political issue. We then assess how different political institutions have responded and conclude that courts will continue to take the leading role.     

The politics of managed competition: public abuse of the private interest

The doctrine of managed competition in health care sought to achieve the social goals of access and efficiency using market incentives and consumer choice rather than governmental regulation and public administration. In retrospect, it demanded too much from both the public and the private sectors. Rather than develop choice-supporting rules and institutions, the public sector has promoted process regulation and benefit mandates. The private health insurance sector has pursued short-term profitability rather than cooperate in the development of fair competition and informed consumer choice. Purchasers have subsidized inefficient insurance designs in order to exploit tax and regulatory loopholes and to retain an image of corporate paternalism. America's health care system suffers from the public abuse of private interests and the private abuse of the public interest.     

Reform and the politics of hybridization in mature health care states

This article examines the cases of three health care states -- two of which (Britain and the Netherlands) have undergone major policy reform and one of which (Canada) has experienced only marginal adjustments. The British and Dutch reforms have variously altered the balance of power, the mix of instruments of control, and the organizing principles. As a result, mature systems representing the ideal-typical health care state categories of national health systems and social insurance (Britain and the Netherlands, respectively) were transformed into distinctive national hybrids. These processes have involved a politics of redesign that differs from the politics of earlier phases of establishment and retrenchment. In particular, the redesign phase is marked by the activity of institutional entrepreneurs who exploit specific opportunities afforded by public programs to combine public and private resources in innovative organizational arrangements. Canada stands as a counterpoint: no window of opportunity for major change occurred, and the bilateral monopoly created by its prototypical single-payer model provided few footholds for entrepreneurial activity. The increased significance of institutional entrepreneurs gives greater urgency to one of the central projects of health policy: the design of accountability frameworks to allow for an assessment of performance against objectives.     

The politics of the selective gaze: Closed Circuit Television and the policing of public space

This paper gives first an explanation for therapid development of Closed Circuit Television (CCTV)throughout Britain. This considers the implicationsof its rapid proliferation on the geographies ofpublic space and highlights the selectivity of thegaze of the surveillance cameras and the consequentpotential for the exclusion of certain groups frompublic space. The paper then extends this by usingresearch from two rural towns to address three basicquestions: how the cameras are used for direct lawenforcement; how this use is governed; and how thepublic react to the use of CCTV. It concludes that bystressing the selectivity of the surveillance anddrawing the implications of this for enforcement andgovernance, and also stressing the extent to which theplacing and timing of the use of the cameras fails toreflect the revealed preferences of the communitiesinvolved.