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.     

Back to the future? Diabetes, HIV, and the boundaries of public health

The control of infectious diseases has traditionally fallen to public health and the clinical care of chronic diseases to private medicine. In New York City, however, the Department of Health and Mental Hygiene (DOHMH) has recently sought to expand its responsibilities in the oversight and management of chronic-disease care. In December 2005, in an effort to control epidemic rates of diabetes, the DOHMH began implementing a bold new plan for increased disease surveillance through electronic, laboratory-based reporting of A1C test results (a robust measure of blood-sugar levels). The controversy A1C reporting produced was relatively contained, but when Dr. Thomas Frieden, New York City health commissioner, called for the state to begin tracking viral loads and drug resistance among patients with HIV, both the medical community and a wider public took notice and have started to grapple with the meaning of expanded surveillance. In the context of the past century of medical surveillance in America, we analyze the current debates, focusing first on diabetes and then HIV. We identify the points of contention that arise from the city's proposed blend of public health surveillance, disease management, and quality improvement and suggest an approach to balancing the measures' perils and promises.     

The fundamental law that shapes the United States health care system: is universal health care realistic within the established paradigm?

In this article, the author draws from his own experience as a doctor in describing the issues the uninsured patient population faces. Pointing out that neither the U.S. Constitution nor case law provides a positive right to health care, the author describes the parameters of federal health care funding and ultimately concludes that universal health care cannot be fully achieved in the U.S.     

What is the goal of access to health care?

This article first examines the justifications for the goal of access to health care and the variations between health systems in their endorsement of individuals' rights to health care irrespective of income, ethnicity, age and other characteristics. It then examines the meanings of the goal of "access" to health care and considers four key dimensions--service availability ("having" access), service utilisation ("gaining" access), the relevance and effectiveness of services and equity of access. These dimensions provide a common framework that can be applied across countries and health systems and employed to assess the extent to which access to health care is actually achieved.     

Another special relationship? Interactions between health technology policies and health care systems in the United States and the United Kingdom

Confronted with similar challenges, the United States and the United Kingdom have adopted very different health technology policies. In the United States, the focus has been on technology creation, in particular the funding of basic biomedical research at the National Institutes of Health. This both reflects and reinforces an innovation-first culture in the United States, including in health. By contrast, the United Kingdom has been much more heavily committed to applied research and evaluative research, including health-technology assessment. That is, while U.S. policy has focused on technology creation, U.K. policy has been more oriented toward technology diffusion. This article surveys the sources of these differences. We consider the impacts of institutional, cultural, and other factors that may explain them, and emphasize that it is hard to disentangle the separate effects of those factors. We conclude with a discussion of the difficulties in drawing cross-national lessons in health technology policy.     

A technocratic fix to the "legitimacy problem"? The Blair government and health care rationing in the United Kingdom

The work of the National Institute for Clinical Excellence, an agency which has recently been created by Tony Blair's Labour government to provide guidance on best clinical practice to the National Health Service, has generated considerable controversy in the United Kingdom. It has been argued that the role which the institute plays in appraising cost effectiveness, especially of expensive new health technologies, constitutes explicit, national rationing. Although the employment of scientific and evidence-based criteria as the basis of decisions might have been expected to secure legitimacy for the institute--even when its recommendations have the effect of denying access to a particular treatment--the reaction to much of its work so far indicates that this goal has not been fully achieved. While alterations to structure and procedure may be considered as possible means of addressing the agency's difficulties, such proposals are not without problems. Consequently, in the final analysis, the British example may serve as a demonstration that the inherently political nature of priority-setting in health care precludes any easy technocratic solution.     

From Apalachin to the Buffalo Project: Obstacles on the path to effective federal responses to organized crime, 1957–1967

The Apalachin meeting of recognized underworld leaders from cities across the USA was held in upstate New York on November 14, 1957. The event, well known to historians and justice system officials, has become a textbook case rarely examined for its larger context of how American government officials learned to confront the organization and strength of the American Mafia, later called La Cosa Nostra (LCN). From 1957 to 1967, three presidents, four attorneys general, and hundreds of federal agents and prosecutors traveled an obstacle-filled path toward investigating, indicting, prosecuting, and convicting Apalachin attendees and their successors. Steps were taken to challenge the power of the mob during the Eisenhower and Kennedy administrations, but they were consistently plagued by false starts, frustrations, and side steps. Each obstacle further instructed policy makers, however, on the need for an intensive and coordinated effort grounded in common goals and interagency cooperation. This article considers six key obstacles to the decade-long quest for a concerted federal initiative against organized crime. It examines how the characteristics and the impact of each obstacle contributed to a meandering and slothful federal response to the Mafia’s power. Lessons learned about how to effectively attack the mob were finally implemented in May 1966 when President Johnson institutionalized Executive agency cooperation, making the Attorney General (AG) the focal point in the war on organized crime. One element in this new initiative was known as the ‘Buffalo Project,’ an experiment commencing officially in January 1967 in Buffalo, New York to concentrate intelligence, investigations, and prosecutive resources working across bureaucratic lines to pursue guilty pleas or convictions. The Project, a closely supervised operation directed by the Justice Department’s Organized Crime and Racketeering Section (OCRS), was conceptualized as a small team of supervisory federal investigators and experienced prosecutors who built cases against local Mafia associates and leaders to withstand the scrutiny of the federal justice system. Assistance was also rendered by state, local, and international organizations. The Project formed a template for the DoJ Criminal Division’s Strike Force program.

Why Does the State Keep Coming Back? Neoliberalism,the State and the Archeon

In this essay I argue that the distinction between neoliberalism and the Westphalian order that is said to precede it (along with populism, authoritarianism and other contemporary phenomenon) are all facets of one and the same phenomenon: archism. Archism is a style of politics based on rule and division. Looking at the work of Derrida, Foucault and Benjamin, I examine the inner workings of archism and how it can be resisted. Above all, I consider the notion of the ‘archeon’; that privileged perch from which the state or law can judge without itself being subject to that judgment. The archeon, I argue is the central node of archism that allows itself to insinuate into any number of myriad forms without appearing to be the same phenomenon. By looking at the way Benjamin subverts the theological origins of the archeon with the idea of a God who abandons the position of judgment, I show a model for how to think differently about archism such that we do not seem eternally fated to choose between the same false dichotomies over and over again.