Health care reform in Germany: patchwork change within established governance structures

Under the pressure of health care reform in the 1990s, interactions among the state, sickness funds, and providers in Germany are said to have entered a new era. We examine this new era by assessing both long-term developments connected to German statutory health insurance (SHI) and related short-term developments of the 1990s. Highly institutionalized rules and practices provide little opportunity for abandoning the historical path of two primary factors: the self-governance of SHI and a strong tradition of a semisovereign state. Some opportunities exist for introducing new ideas, rearranging priorities, softening rules, and adding new complex rules and procedures in a fairly fragmented policy-making system, perhaps even because of fragmentation. Yet reforms that depart from the status quo are severely limited by strong legal and administrative traditions and established rules of the game. These restrictions tend to reinforce state intervention, prevent the emergence of consistent and coherent visions of future health policy, and stifle policy innovation and implementation. In sum, reform measures tend to remain well within the priorities established within state and corporatist governance structures.     

The new institutionalist approaches to health care reform: lessons from reform experiences in Central Europe

This article discusses the applicability of the new institutionalism to the politics of health care reform in postcommunist Central Europe. The transition to a market economy and democracy after the fall of communism has apparently strengthened the institutional approaches. The differences in performance of transition economies have been critical to the growing understanding of the importance of institutions that foster democracy, provide security of property rights, help enforce contracts, and stimulate entrepreneurship. From a theoretical perspective, however, applying the new institutionalist approaches has been problematic. The transitional health care reform exposes very well some inherent weaknesses of existing analytic frameworks for explaining the nature and mechanisms of institutional change. The postcommunist era in Central Europe has been marked by spectacular and unprecedented radical changes, in which the capitalist system was rebuilt in a short span of time and the institutions of democracy became consolidated. Broad changes to welfare state programs were instituted as well. However, the actual results of the reform processes represent a mix of change and continuity, which is a challenge for the theories of institutional change.     

Learning legal reasoning while rejecting the oxymoronic status of feminist judicial rationalities: a view from the law classroom

One misconception accompanying the idea of a feminist judgment is that feminist judgment is inherently at odds with the putative neutrality of the “judge” as a “neutral” adjudicator. Many lawyers, scholars and law students tend to assume that when deliberating as a judge, feminism(s) simply has/have no rightful or rational place, relevance or bearing upon the process or the outcome and that such a “non-neutral” view will necessarily deviate from the standard canons of judicial reasoning by embodying an unacceptable bias. Introducing students to the “grammar” of reasoning in an undergraduate course dedicated to both general critical reasoning and legal reasoning, however, presented an ideal opportunity for students to encounter in greater intimacy the interpretive openness of law and the indeterminacies that argument alone can never ultimately resolve without recourse to deeper positional commitments. By stepping into the role of judge, having studied the techniques, inherent malleability and limitations of legal argument, students could explore for themselves the range of argumentatively defensible interpretations and outcomes possible in any given legal case. In the process, the students could appreciate not only the open textured nature of judgment and legal reasoning more richly, but also see the “rationality” of feminist judgment as a fully plausible alternative to non-feminist “rationality” and judgment.     

Rebuilding the past: health care reform in post-Katrina Louisiana

After Hurricane Katrina, there was good reason to believe that a gaping window of opportunity had opened for Louisiana to revamp its safety-net health care system. But two years of discussions among stakeholders within Louisiana and extensive negotiations with federal officials resulted in no such change. This article argues that any explanation for this outcome needs to incorporate both structure and process. In terms of structure, the rules of the Medicaid disproportionate-share hospital (DSH) program give states substantial independent authority to decide which hospitals to fund. Federal authorities could not force Louisiana, which had historically turned its DSH money over to the state hospital system, to redirect it toward an insurance expansion. In the process of negotiation after Katrina, those who defended the institutions wedded to the prestorm status quo conducted a better strategy than their challengers. They narrowed the purview of the Louisiana Health Care Redesign Collaborative, set up to propose changes in the safety net to the federal government, such that the question of whether to rebuild Charity Hospital in New Orleans was off the table. Meanwhile, on a separate track, the state and the Department of Veterans Affairs successfully pursued a plan to jointly build replacement hospitals.     

Health care and the labor market: learning from the German experience

Many observers have begun to question the U.S. reliance on an employment-based private health insurance system. In thinking about the future of this system, it is instructive to examine the German experience. The German health insurance system is almost entirely organized and financed around the labor market. In recent years, the German labor market has changed in several ways. Among other changes, more German women now work, the proportion of retirees in the population has increased, the share of manufacturing in employment has declined, and the economy has become more open. These labor market changes have made it more difficult to organize health insurance around employment in Germany. Recent changes in the German health insurance system have, to some extent, decoupled health insurance from employment. This decoupling is likely to continue as the labor market changes further. We explore the implications of this experience for the United States.     

Health care of the disadvantaged: the elderly

This paper explores threats to the maintenance and expansion of public commitment to financing health care for the elderly. Threats come from rising costs that increase financial burdens, especially on low-income elderly; efforts to contain costs that may undermine benefits; and financing initiatives that treat the elderly as the sole revenue source for addressing problems in that age group. A review of these threats provides lessons not only for sustaining and improving health care for the elderly, but also for policy toward equally or more disadvantaged groups.     

Health care system change and the cross-border transfer of ideas: influence of the Dutch model on the 2007 German health reform

To increase understanding of the cross-border transfer of ideas through a case study of the 2007 German health reform, this article draws on Kingdon's approach of streams and follows two main objectives: first, to understand the extent to which the German health reform was actually influenced by the Dutch model and, second, in theoretical terms, to inform inductively on how ideas from abroad enter government agendas. The results show that the streams of problem recognition and policy proposals have not been predominantly influenced by the cross-border transfer of ideas from the Netherlands to Germany. The Dutch experience was taken into consideration only after a policy window opened by a shift in politics in the third, the political, stream: the change of government in 2005. In many respects, the way Germany learned from the Netherlands in this case sharply contrasts with an image of solving policy problems by either lesson drawing or transnational deliberation. Instead, the process was dominated by problem solving in the sphere of politics, that is, finding a way to prove the grand coalition was capable of acting.     

从《精神卫生法》看精神障碍患者的知情同意权

知情同意权是医患关系中的主要问题之一,新出台的《精神卫生法》在多个条文中明确规定了精神障碍患者的知情同意权,成为精神病患者知情同意权的基本法律依据。本文立足于知情同意权的一般法理,梳理《精神卫生法》中精神障碍患者知情同意权的法律规定,以此为基础探讨精神障碍患者知情同意权的基本内容。