Public values, health inequality, and alternative notions of a "fair" response

The fact that disadvantaged people generally die younger and suffer more disease than those with more resources is gaining ground as a major policy concern in the United States. Yet we know little about how public values inform public opinion about policy interventions to address these disparities. This article presents findings from an exploratory study of the public's values and priorities as they relate to social inequalities in health. Forty-three subjects were presented with a scenario depicting health inequalities by social class and were given the opportunity to alter the distribution of health outcomes. Participants' responses fell into one of three distributive preferences: (1) prioritize the disadvantaged, (2) equalize health outcomes between advantaged and disadvantaged groups, and (3) equalize health resources between advantaged and disadvantaged groups. These equality preferences were reflected in participants' responses to a second, more complex scenario in which trade-offs with other health-related values - maximizing health and prioritizing the sickest - were introduced. In most cases, participants moderated their distributive preferences to accommodate these other health goals, particularly to prioritize the allocation of resources to the very sick regardless of their socioeconomic status.     

Equality and Distributions of Inheritance in Families

Inheritance distributions in families involve people in deciding about the meaning and application of equality. Using a distributive justice perspective, this study used hypothetical vignettes to examine 89 older adults' judgements about inheritance distributions to children under systematically varied conditions related to a child's relative deservedness or need. Participants endorsed the cultural norm of equal distribution where there was little information about circumstances. When they knew an adult child's circumstances, 80 percent of participants qualified their adherence to equality in situations that evoke other distributive principles which are important in families, for example, reciprocity and responsiveness to need. Decisions about inheritance distributions involve adapting social norms to different family circumstances, taking account of specific roles and relationships, and giving personal meanings to the concept of equality.     

Reframing the racial disparities issue for state governments

Although racial and ethnic disparities in health have been on the federal government's agenda since 1985, no policy reforms have significantly reduced disparities. The question arises whether states can effectively address this issue without waiting for solutions from the national government. The purpose of this article is to propose ways of reframing the disparities issue that might give state policy makers more leverage and might strengthen political will to address the issue. I suggest a moral frame based on a concept of distributive justice in which medical care must be distributed according to need. I explain the rationales for such a frame and consider its strategic advantages and disadvantages. In the last section, I suggest some policies based on this framing that are within the power of state legislatures.     

Reflecting Upon Etic and Emic Perspectives on Distributive Justice

The study of distributive justice may be examined using two research perspectives. The first, etic perspective seeks to unveil the common characteristics that characterize the spectrum of distributive justice phenomena across different cultures and circumstances. This perspective focuses on the universal aspects of justice behavior, namely, general laws and causal explanations. The second, emic perspective focuses on the ways in which justice behavior is expressed in specific socio-cultural contexts. This paper proposes a three-part reflection on these two perspectives on distributive justice. First, we review the ways in which the emic, culturally specific perspective has hitherto been incorporated into research on distributive justice; second, we examine the ways which the etic and emic perspectives are employed in two empirical studies on justice perception in Israel; and, finally, we suggest possible ways in which an extended emic perspective can be further incorporated in the study of distributive justice. An earlier version of this paper was presented at the Social Justice Conference, University of Bremen, Bremen, Germany, March 2005.     

Deconstructing Deliberation in the Appraisal of Medical Technologies: NICEly Does it?

Appraisals of medical technologies undertaken by the National Institute for Health and Clinical Excellence (NICE) have significant implications for the setting of priorities for health care expenditure in the NHS in England and Wales. NICE has been characterised as a deliberative body, an evaluation which reflects the recent attention paid by those working within the health policy community to the establishment of mechanisms which deliver procedural justice, in the absence of societal consensus upon the substantive values which should underpin distributive choices in health care. This article critically interrogates the assessment of NICE as deliberative in character. It also considers the relationship between legitimacy and deliberation in this policy context, in light of the claim that 'thickening proceduralisation' by establishing and enhancing deliberative structures and processes is a useful strategy for addressing regulatory problems.     

Medicare program; clarification of Medicare's accrual basis of accounting policy--HCFA. Final rule

This final rule revises the Medicare regulations to clarify the concept of "accrual basis of accounting" to indicate that expenses must be incurred by a provider of health care services before Medicare will pay its share of those expenses. This rule does not signify a change in policy but, rather, incorporates into the regulations Medicare's longstanding policy regarding the circumstances under which we recognize, for the purposes of program payment, a provider's claim for costs for which it has not actually expended funds during the current cost reporting period.     

Access to medicine in an era of fractal inequality

This article evaluates the legitimacy and degree of inevitability of unequal access to medicine. The author introduces 'fractal inequality' to the access issue by using the term to describe skewed patterns in distributions of income and wealth that lead to reallocative effects of higher spending on health care by the wealthiest that can cascade down the distributive ladder. 'Fractal inequality' is transposed to the U.S. health care sector to explain the trend away from medical need toward ability to pay. The author cautions U.S. policymakers to consider international access problems instead of exacerbating those issues when domestic access to care policies is debated in a vacuum. The author also analyzes some policy proposals designed to reduce inequities in the global trade of medicine.     

The Effectiveness of the EU's Ozone Policy

Has the EU's ozone policy been effective? In other words: What caused the 90 per cent phase-out of ozone depleting substances (ODS) within the EU? Was it due to an EU-wide regulatory approach, to national circumstances, or to the Montreal Protocol? As EU's environmental policy has not been overly successful so far, it would interesting to know why ozone policy is an area where the EU and its Member States have reached targets effectively over a relatively short time. We suggest that the effectiveness of EU's ozone policy is due to two factors that together secured this rapid phase-out. First, the ozone policy was enacted by means of an EU regulation – rather than by directives – which required all Member States and all larger ODS-generating corporations to implement a ban simultaneously. Second, with the US administration making a u-turn and the increased availability of ODS-substitute chemicals, Europe saw a political opportunity to speed up the phase-out process. A limited study of the phase-out of ODS in Spain supports this argument. While the EU's ozone policy has been effective, its success owes much to particular economic and political circumstances associated with the issue of ozone depletion.     

重大公共卫生事件下的刑事政策模式

坚持道德理性而否认规范理性,或者主张规范理性而排斥道德理性,都是有失偏颇的。规范目的与整体法秩序目的是两种不同层次的目的,两者互补互济、相辅相成,能有效衡平社会伦理道德与刑法规范的关系,并使刑法适用保持活性与弹力,充分迎合司法实践需要。信守规范目的而忽视整体法秩序的刑事政策,有时不利于维护社会共同体利益。信奉整体法秩序目的而忽视规范的刑事政策,可能不利于保护共同体成员的个人权益。重大公共卫生事件下,传统刑事政策面临诸多困境,应贯彻刑事政策发展模式。刑事政策发展模式要求正当事由得到现实化延伸,合理调适定罪量刑标准,扩展刑法解释体系范畴。刑事政策发展模式下,需要严控适用范畴,合法约束模糊管理,有效限制道德理性和规制辩证逻辑。     

Means and Capabilities in the Discussion of Distributive Justice*

Abstract. Dworkin's equality of resources can be interpreted as a proposal that integrates distributive criteria taken from both equality of means and equality of capabilities, and overcomes the risks of subjectivism, overrigidity and perfectionism inherent in theories of welfare, means and capabilities respectively. This can be achieved by concentrating on arrangements of justice working within the parameter of equality of resources that equalize capabilities at a level of minima, thus avoiding the perfectionist risk and, once the threshold that ensures autonomous subjects is passed, ruled by criteria taken from theories of means. In such a task, the concept of moral person will be used as the criterion for determining the threshold of autonomy, and not only will it allow for the discrimination between the different circumstances that make the application of distributive criteria possible, but it will also specify the circumstances in which it is possible to attribute responsibility to an agent.     

Social preferences for the inclusion of indirect benefits in the evaluation of publicly funded health services: results from an Australian survey

The inclusion of both monetary and non-monetary indirect benefits in economic evaluations of public health programmes and services can have significant distributive effects between patient groups. As a result, some patients may be advantaged and others disadvantaged for reasons not directly related to health outcomes or (direct) treatment costs. In pluralistic democracies, there is a case for consulting the community on the fairness of policies that have such distributive implications. This paper reports the results of two pilot studies aimed at uncovering the preferences of the Australian public for the inclusion of indirect benefits in the evaluation of services for its national health scheme, Medicare. The initial survey found some support for taking account of non-monetary indirect benefits - for example, the social contribution made by parents of young children and carers of elderly relatives. By contrast, there was little support for giving high taxpayers priority access to general Medicare services, to life-saving organ transplants, or to very costly drugs, despite the indirect social benefits of doing so. However, such support increased significantly in the follow-up study when the outcomes were characterised as certain, identifiable and health related, and the opportunity costs of failing to take account of indirect benefits were made very clear. The follow-up survey provided evidence of public scepticism about the willingness or ability of government to use additional tax receipts for socially beneficial purposes, and/or a preference for programmes and services that focus on health rather than welfare more generally.     

Bicameralism and Geographic Politics: Allocating Funds in the House and Senate

Because they represent different kinds of constituencies—states versus parts of states—senators and House members have different incentives in constructing federal distributive programs. In order to claim credit for providing particularized benefits, House members need to use policy tools—earmarks and narrow categorical programs—that target funds to their constituencies. Senators, by contrast, are able to claim credit for the large formula grants that distribute the bulk of intergovernmental grant money. Examining House‐Senate interactions in one of the largest distributive programs, federal aid to states for surface transportation, I show that the different bases of representation in the House and Senate structure the chambers' preferences on distributive programs and affect the outcomes of interchamber conflicts.     

The work the document does: research, policy, and equity in health

At the center of the politics of health equity, in many countries and circumstances, stands a signal report of research. This article is concerned with what might be described as the architecture of such documents, including how they are produced and organized and the relationships they demonstrate with others that parallel, precede, and succeed them. The article examines how scientific and political authority is established and comments on the evidence of cross-national learning that these documents reveal. It discusses differences in how the problem of health equity is constructed in different countries and how research findings are converted into policy recommendations. It begins to trace a process of implementation by noting how these documents are referred to and written about. The argument is that the politics of health equity are expressed or realized in the documents and reports, which are its principal vehicle. This is not to claim that there is no world beyond the text or that the world somehow is a text, but that to fully understand that world we must understand the text and the work it does.     

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.     

The invention of health law

By default, the courts are inventing health law. The law governing the American health system arises from an unruly mix of statutes, regulations, and judge-crafted doctrines conceived, in the main, without medical care in mind. Courts are ill-equipped to put order to this chaos, and until recently they have been disinclined to try. But political gridlock and popular ire over managed care have pushed them into the breach, and the Supreme Court has become a proactive health policy player. How might judges make sense of health law's disparate doctrinal standards? Scholars from diverse ideological starting points have converged toward a single answer: the law should look to deploy medical resources in a systematically rational manner, so as to maximize the benefits that every dollar buys. This answer bases the orderly development of health care law upon our ability to reach stable understandings, in myriad circumstances, of what welfare maximization requires. In this Article, I contend that this goal is not achievable. Scientific ignorance, cognitive limitations, and normative disagreements yield shifting, incomplete, and contradictory understandings of social welfare in the health sphere. The chaotic state of health care law today reflects this unruliness. In making systemic welfare maximization the lodestar for health law, we risk falling so far short of aspirations for reasoned decision making as to invite disillusion about the possibilities for any sort of rationality in this field. Accordingly, I urge that we define health law's aims more modestly, based on acknowledgement that its rationality is discontinuous across substantive contexts and changeable with time. This concession to human limits, I argue, opens the way to health policy that mediates wisely between our desire for public action to maximize the well being of the many and our intimate wishes to be treated noninstrumentally, as separate ends. I conclude with an effort to identify the goals of health law, so constructed, should pursue and to suggest how a strategy of accommodation among these goals might apply to a variety of legal controversies.     

建设用地增减挂钩制度：问题与出路

增减挂钩制度在实践运行中偏离其原有的设计初衷发生异化,所以该制度在进一步推动和完善时遭到了社会各界的质疑。但是笔者认为,该制度具有相当的科学合理性,并且在我国当今建设用地短缺和集体土地使用低效的国情下有着重要的意义,不容轻易否定,但应找准问题的症结,在技术上对该政策进行完善。     

Purchasing power: business and health policy change in Massachusetts

As in many states around the country, health care costs in Massachusetts had risen to an unprecedented proportion of the state budget by the early 1980s. State health policymakers realized that dramatic changes were needed in the political process to break provider control over health policy decisions. This paper presents a case study of policy change in Massachusetts between 1982 and 1988. State officials formulated a strategy to mobilize corporate interests, which were already awakening to the problems of high health care costs, as a countervailing power to the political monopoly of provider interests. Once mobilized, business interests became organized politically and even became dominant at times, controlling both the policy agenda and its process. Ultimately, business came to be viewed as a permanent part of the coalitions and commissions that helped formulate state health policy. Although initially allied with provider interests, business eventually forged a stronger alliance with the state, an alliance that has the potential to force structural change in health care politics in Massachusetts for years to come. The paper raises questions about the consequences of such alliances between public and private power for both the content and the process of health policymaking at the state level.     

Access to health care for undocumented migrants: a comparative policy analysis of England and the Netherlands

The presence of undocumented migrants is increasing in many Western countries despite wide-ranging attempts by governments to increase border security. Measures taken to control the influx of immigrants include policies that restrict access to publicly funded health care for undocumented migrants. These restrictions to health care access are controversial, and evidence suggests they do not always have the intended effect. This study provides a comparative analysis of institutional, actor-related, and contextual factors that have influenced health care policy development on undocumented migrants in England and the Netherlands. For undocumented migrants, England restricts its access to care at the point of service, while the Netherlands restricts through the payment system for services. The study includes an analysis of policy papers and semistructured, in-depth interviews with various actors in both countries. Findings confirm the influence of such contextual factors as immigration considerations and cost concerns on health care policy making in this area. However, these factors cannot explain the differences between the two countries. Previously enacted policies, especially the organization of the health care system, affected the kind of restrictions for undocumented migrants. Concerns about the side effects of generous treatment of undocumented migrants on other groups played a substantial role in formulating restrictive policies in both countries. Evidently, policy development and implementation is critically affected by institutional rules, which govern the degree of influence that doctors and professional medical associations have on the policy process.     

public Health Ethics From Foundations and Frameworks to Justice and Global public Health

Ethics dilemmas have been present throughout the history of public health, and bioethics has devoted considerable attention to issues relevant to public health. Only recently, however, has public health ethics emerged as a recognized subfield of bioethics. Public health ethics requires that public health improvement come through just and respectful means. Bioethics in the future not only will take on more issues of public ethics, but will apply it extensive scholarship in distributive justice to questions of global public health.     

Is the doctor in? The evolving role of organized medicine in health policy

Until recently, physicians were viewed as the dominant player in health policy. Now, however, they compete with many other effective interest groups. This article analyzes this changing role, and specifically how organized medicine has changed its approach to influencing health policy. The essay begins with a review of the reasons for the growth and subsequent decline of physicians' influence. This is followed by a case study of physician payment reform under Medicare, which illustrates the ways in which organized medicine chooses when and when not to cooperate with government. The article concludes with a discussion of where physicians are likely to continue to be influential in future health policy reform. Three such areas are noted: payment policy, quality and clinical innovation, and medical education and training.