Aspects of the evolution of extra-legal protection in Bulgaria (1989–1999)

In this paper I look at the interplay between organised crime, law, and the state and argue that the evolution of organised crime organisations in Bulgaria was shaped by the dynamic transformation of the legal and economic environment during the 90s, by policies of the state, such as, for example, the regulation of the private security and insurance industries (in 1994 and 1998 respectively), which mafia-like organisations used as fronts for their activities during the 90s and by the ability of organised crime organisations to adapt to the constantly changing conditions. In the first section of the paper I look at the emergence of the private security and private protection industries in Bulgaria with an emphasis on the development of organisations using the threat of violence to settle disputes, discourage competition, retrieve stolen property and collect debts. In the second section of the paper, I follow the transformation of certain type of private security companies into insurance companies, which directed their activities at properties liable to risk, for instance cars and small shops. They enjoyed an advantage over ordinary insurance companies because they possessed greater information about the risks, which could affect the property of their clients, for example theft (car theft in particular). The concluding section discusses the development of silovi grupirovki (the Bulgarian name for organised crime organisations) after 1998 when a very strict licensing regime for insurance companies was introduced and alleged to be mafia-like organisations were removed from the insurance market.

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.     

HMO promotion and the privatization of health care in Chile

Since 1973 the Chilean junta has privatized sectors of the national economy. This paper analyzes the country's policy process of promoting private medical programs through HMO-like plans (ISAPREs, or Institutes of Provisional Health). These plans have captured less than half of their originally anticipated market share. It is argued that the future performance of ISAPREs will be undermined by their limited maternal benefits, their targeting to a small upper-income group which cannot sustain many private medical programs, and competition with less expensive yet equally competent public medical programs. The paper briefly compares privatization in Chile with the experiences of other countries, and specifically contrasts the restructuring of health services under military rule in Chile with those of Argentina and Uruguay. The paper concludes that the Chilean experience with HMOs epitomizes the perils of planning health care during short-term periods of economic prosperity as well as failing to consult medical care providers and consumers.     

Charter rights & health care funding: a typology of Canadian health rights litigation

Canadian health consumers have increasingly relied on the Charter of Rights and Freedoms to demand certain therapies and reasonably timely access to care. Organizing these cases into a 5-part typology, we examine how a rights-based discourse affects allocation of health care resources. First, successful Charter challenges can, in theory, lead to courts granting and enforcing positive rights to therapies or to timely care. Second, courts may grant a right to certain health services; however, subsequently government fails to deliver on this right. Third, successful litigation may create negative rights, i.e. rights to access care or private health insurance without government interference. Fourth, consumers can fail in their legal pursuit of a right but galvanize public support in the process, ultimately effecting the desired policy changes. Lastly, a failed lawsuit can stifle an entire advocacy campaign for the sought-after therapies. The typology illustrates the need to examine both legal and policy outcomes of health right litigation. This broader analysis reveals that the pursuit of health rights seems to have caused largely a regressive rather than progressive impact on Canadian Medicare.     

Insurance Discrimination on the Basis of Health Status: An Overview of Discrimination Practices, Federal Law, and Federal Reform Options

Actuarial underwriting, or discrimination based on an individual's health status, is a business feature of the voluntary private insurance market. The term "discrimination" in this paper is not intended to convey the concept of unfair treatment, but rather how the insurance industry differentiates among individuals in designing and administering health insurance and employee health benefit products. Discrimination can occur at the point of enrollment, coverage design, or decisions regarding scope of coverage. Several major federal laws aimed at regulating insurance discrimination based on health status focus at the point of enrollment. However, because of multiple exceptions and loopholes, these laws offer relatively limited protections. This paper provides a brief overview of discrimination practices, the federal law, and federal reform options to manage discriminatory practices in the insurance and employee health benefit markets.     

The private sector and competition in health care markets

This paper reviews the historical trends in the regulatory and competitive approaches to containment of health care costs, covering efforts in both public and private sectors. The current interest in the potential of private-sector initiatives to stimulate competition in health care insurance and provider markets is highlighted. Since neither the workings of competition in health care nor the role and impact of the private sector in stimulating such competition are well understood, the concluding section discusses important research issues surrounding these topics.     

Explaining health care system change: problem pressure and the emergence of "hybrid" health care systems

In this article, we will further the explanation of the state's changing role in health care systems belonging to the Organisation for Economic Cooperation and Development (OECD). We build on our analysis of twenty-three OECD countries, which reveals broad trends regarding governments' role in financing, service provision, and regulation. In particular, we identified increasing similarities between the three system types we delineate as National Health Service (NHS), social health insurance, and private health insurance systems. We argue that the specific health care system type is an essential contributor to these changes. We highlight that health care systems tend to feature specific, type-related deficiencies, which cannot be solved by routine mechanisms. As a consequence, non-system-specific elements and innovative policies are implemented, which leads to the emergence of "hybrid" systems and indicates a trend toward convergence, or increasing similarities. We elaborate this hypothesis in two steps. First, we describe system-specific deficits of each health care system type and provide an overview of major adaptive responses to these deficits. The adaptive responses can be considered as non-system-specific interventions that broaden the portfolio of regulatory policies. Second, we examine diagnosis-related groups (DRGs) as a common approach for financing hospitals efficiently, which are nevertheless shaped by type-specific deficiencies and reform requirements. In the United States' private insurance system, DRGs are mainly used as a means of hierarchical cost control, while their implementation in the English NHS system is to increase productivity of hospital services. In the German social health insurance system, DRGs support competition as a means to control self-regulated providers. Thus, DRGs contribute to the hybridization of health care systems because they tend to strengthen coordination mechanisms that were less developed in the existing health care systems.     

Back to the future? Health benefits, organized labor, and universal health care

The umbrella of employment-based health benefits is growing increasingly threadbare. As a result, health benefits are once again a major arena of labor-management strife, and once again calls for universal health care by many labor leaders mask important differences between them over health care reform. Some labor leaders advocate a bottom-up mobilization in support of a single-payer solution that would dismantle the system of job-based benefits rooted in private insurance. Others stake their health care strategy on wooing key business leaders to be constructive partners in some kind of unspecified comprehensive reform of the health system. Organized labor faces enormous obstacles, both institutional and ideological, to forging an effective united front to fight for comprehensive, high-quality, affordable health care for all. Two entrenched features of the shadow welfare state of job-based benefits, notably the Employee Retirement Income Security Act (ERISA) of 1974 and the union-run health and welfare funds created under the Taft-Hartley Act, remain daunting barriers on the road to reform, exacerbating tensions and differences within organized labor. Moreover, a dramatic ideological schism in the labor movement about its future direction vexes its stance on health care reform. These ideological differences fuel vastly different views within organized labor about how best to confront the unraveling of job-based health benefits and the growing popularity among business leaders, insurers, and public officials of the "individual-mandate" solution, which would penalize people who do not have adequate health insurance.     

Empire and the business of health insurance.

I examine the development of privately provided insurance since World War II, giving special attention to Empire Blue Cross, and argue that the competition between employers and unions for the loyalty of workers after the passage of the Taft-Hartley Act helped diffuse private health insurance benefits already favored by federal policies. For-profit insurers did not challenge the privileged status of Blue Cross plans because they recognized the political benefits that the plans offered and because they did not wish to offend the plans' sponsors. A relatively easy and profitable business, health insurance has been greatly disturbed by the system inflation accompanying the introduction of Medicare and Medicaid programs. Now self-insurance and various managed-care schemes are major threats. The future may bring consolidation and the strengthening of pools, just the opposite of today's system fragmentation.     

Nanotechnology: The Challenge of Regulating Known Unknowns

Media reports of the health hazards posed by nano-sized particles (NSPs) have turned a white hot spotlight on the risks of nanotechnology. Worried about the risks posed to workers producing nano-materials, the Washington Post has labeled nanotechnology a "seat-of-the-pants occupational health experiment." This article examines our emerging knowledge base about the hazards of two types of exposure: inhalation of NSPs and topical application of products containing NSPs. It argues that a clear-eyed evaluation of the benefits and risks of nanotechnology is made extremely difficult by the marriage of a complex science with a venture capitalist-like hype. It then suggests that, absent additional statutory authority, governmental regulators cannot readily address the risks posed by these products. This regulatory inaction leaves a significant role for the private insurance market, a role that regulators should support in tangible ways outlined in the article.     

Congress advances on health care reform: one step at a time

In adopting the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Congress made a series of small but significant steps toward improving access to health care benefits. The Act's centerpiece is its new requirements for group health plans and for the health insurance industry for assuring portability, access, and renewability of health insurance coverage. Of nearly equal importance is the pilot program established for testing the viability of medical savings accounts. Other health-related changes include adjustments in the rules governing duplication and coordinating of Medicare-related plans, recommendations with respect to privacy of health information of employees, an increase in the deduction for health insurance costs for self-employed individuals, and permission for unemployed persons to make withdrawals from IRAs and other qualified plans for certain medical services' costs. This article summarizes these and other key provisions of HIPAA.     

Disability Income Insurance: The Private Market and the Impact of Genetic Testing

This article discusses the disability insurance industry in order to provide context regarding the potential impact of genetic testing on disability insurance. It describes disability income insurance, exploring both the protection it offers and its main contract provisions. It goes on to describe the private insurance market and the differences between group and individual insurance, and concludes with implications of genetic testing with respect to the private disability insurance market.     

Constitutional Reasoning in Private Law: The Role of the CJEU in Adjudicating Unfair Terms in Consumer Contracts

This article explores the—often controversial—role of the CJEU as an interpreter of Directive 93/13/EEC on unfair terms. A fundamental problem that any modern system of private law must address is how to combine two types of provisions: those that are intended to facilitate private ordering through voluntary transactions, and those setting out certain mandatory terms that are intended to protect vulnerable consumers against risks inherent to free market transactions. This article argues that, in response to the failure of various legislative initiatives, the Court's jurisprudence has acquired both a regulatory dimension and a constitutional dimension. The emergent judicial regime illustrates an important departure from a rule‐based conception of private law, based on private autonomy as a stand‐alone value, towards an innovative conception that extends proportionality analysis into substantive private law but avoids one‐sided outcomes.     

Water Regulation and Pre-payment Meters

This paper provides a study of the use of law to invoke and protect the interests of poorest consumers of the privatized water industry. It focuses upon the introduction of pre-payment devices by water companies and the legal action taken to prevent their use. The context for the study lies in the privatization of the water industry in 1989, one of the last major acts in a decade in which the transfer of public enterprises into private ownership had become one of the self-proclaimed 'flagship' policies of successive Conservative governments. The claims which surrounded the application of the policy to water were familiar: private ownership produced efficiency, effective management, and attentiveness to customers' needs. Essentially, the sale of public assets created benefits for everyone. This article finds the claim to be false. It considers the social engineering role of law in attempting to protect the interests of poorest consumers, highlighting the resources — individual, community, and political — which required mobilization in order to give effect to potential remedies. It concludes by suggesting that not only is access to the law differentiated by power and resources, but that compliance with it is also mediated by the same inequalities.     

Different countries, different needs: the role of private health insurance in developing countries

This article discusses the role of private health insurance (PHI) in developing countries. Three broad regional clusters are identified that share similar characteristics and policy challenges for the effective integration of private insurance into national health care systems: (1) Latin America and Eastern Europe, where there are already developed insurance industries facing important market and policy failures; (2) the Middle East/North Africa region and East Asia, where there is a projected strong growth of PHI that needs to be accompanied by efficient regulation; and finally, (3) South Asia and Sub-Saharan Africa, where PHI will only play a marginal role in the foreseeable future while the scaling up of small-scale, nonprofit insurance schemes appears to be of critical importance. Overall, this survey shows that the role of private insurance varies depending on the economic, social, and institutional settings in a country or region. Private health insurance schemes can be valuable tools to complement existing health-financing options only if they are carefully managed and adapted to local needs and preferences.     

Recent developments in employee benefits law

The first part of this article highlights important judicial developments involving employee benefits and the Employee Retirement Income Security Act of 1974 ("ERISA"), as amended, during the latter part of 2003 and the first part of 2004, including the most significant U.S. Supreme Court and federal circuit court decisions. The second part covers recent legislative and regulatory developments in employee benefits law. This article is not meant to be exhaustive, but discusses the more important developments during 2003-2004, with particular focus on issues of concern to the insurance industry.     

Energy Crime,Harm, and Problematic State Response in Colorado: A Case of the Fox Guarding the Hen House?

Crime related to energy extraction is an emerging area of interest among green and critical criminologists. This paper contributes to that developing work by examining the political economy of harm and crime associated with the oil and natural gas industry in rural Colorado. Specifically, we examine problematic state regulatory response to citizens’ complaints regarding a range of harms caused by private industry (e.g., water pollution, adverse human health consequences, and domestic livestock death). In this paper, we draw on content analysis of formal complaints filed by citizens to the state, ethnographic work, and intensive interviews with citizens seeking relief from problematic or abusive industry practices. Our analysis illuminates how the state documents these practices, how citizens experience them, and how the state dilutes and deflects the externalities of energy extraction to produce additional harm.     

The Constitutionality of Mandates to Purchase Health Insurance

Health insurance mandates have been a component of many recent health care reform proposals. Because a federal requirement that individuals transfer money to a private party is unprecedented, a number of legal issues must be examined. This paper analyzes whether Congress can legislate a health insurance mandate and the potential legal challenges that might arise, given such a mandate. The analysis of legal challenges to health insurance mandates applies to federal individual mandates, but can also apply to a federal mandate requiring employers to purchase health insurance for their employees. There are no constitutional barriers for Congress to legislate a health insurance mandate as long as the mandate is properly designed and executed, as discussed below. This paper also considers the likelihood of any change in the current judicial approach to these legal questions.     

Secret weapon: the "new" Medicare as a route to health security

Over the past twenty years, Medicare has been transformed from a single-payer insurer into a hybrid of complementary public and private insurance arrangements. Despite creating ongoing controversy, these changes have resulted in an ironic and largely overlooked strategic potential: Medicare's evolving hybrid form makes it the most promising vehicle for overcoming the historical obstacles to universal health insurance in the United States. To make this surprising case, we first explore the distinctive political dynamics of programs that, like today's Medicare, are hybrids of public and private arrangements. We then consider how these political dynamics might circumvent past barriers to universal health insurance. Finally, we discuss the strengths and weaknesses of alternative pathways through which Medicare could be expanded to promote health security.