Why don't courts treat hospitals like tanks for liquefied gases? Some reflections on health care antitrust enforcement

In this article, I use the Federal Trade Commission and the Department of Justice 2004 report Improving Health Care: A Dose of Competition as an occasion to comment on two specific issues that have arisen in health care antitrust: the recent string of losses by the enforcement agencies in hospital merger cases and an antitrust exemption for physicians to bargain collectively with health insurers. One of the more salient facts about health care antitrust enforcement is the notable recent lack of success of the enforcement agencies in hospital merger cases. This may be due to judges and juries holding views of hospital markets as being different from markets for other goods and services. My conclusion is that hospitals are an industry with unique attributes, but nothing about the specifics of the health care industry suggests that the unregulated use of market power in this industry is socially beneficial. As a consequence, the antitrust laws should be enforced here as in any other industry. Countervailing power is an issue that has come to the fore in health care antitrust. Physicians have explicitly asked for legislative exemption from the antitrust laws in order to bargain collectively with insurance companies, as a means of counteracting insurers' monopsony power. It is not clear that health insurers possess significant monopsony power. Even if they do, bestowing monopoly power on physicians will not necessarily improve matters. Active antitrust enforcement in insurance markets is the correct response, not blanket exemptions for providers.     

Obstacles to dependent health care access in Oregon: health insurance or health care?

In the 1980s, Oregon was one of a handful of "states that could not wait" for national health care reform. Oregon's chosen approach to reform was predicated on two widely accepted assumptions. First, universal access to health care is best achieved by universal access to health insurance. Second, universal access to health care could best be achieved, at least politically, by incrementally building upon the existing health care delivery and insurance system. This article questions both of these assumptions in light of Oregon's decade-long experience in trying to expand access to health care among its dependent population.     

Redressing the imbalanced political market for health policy: a role for the state attorney general?

In current discussions of "procompetitive" approaches to health policy, the enforcement of antitrust laws in health care markets is a strategy that has attracted increasing attention: the filing of consumer-oriented health suits provides a means to "redress" the typically imbalanced "political market" in health policy. This study examines an important aspect of the antitrust enforcement process, the decision by a state attorney general to undertake an aggressive antitrust enforcement program in the health area. Three variables were found to explain this decision: the political needs of a "politician-supplier," the organizational resources of a strategic institutional position, and the availability of a relatively favorable policy arena. An assessment of the future role of state attorneys general in this area suggests that their health antitrust initiatives will increase, but that various political and resource constraints are likely to inhibit their aggressiveness in pursuing these actions.     

What prompts health care policy change? On political power contests and reform of health care systems (the case of Canada and Israel)

This article attempts to shed light on the complexity inherent in health care reform policies in the context of political power contests that trigger the changes imposed on the health care system. Rather than being solely a response to financial circumstances, as it is often claimed, we argue that these political contests lead to many of the changes in the systems. Furthermore, changes do not necessarily occur when worrying symptoms appear in the system, but rather when the contest reaches a peak and when neither side involved can emerge from the contest as winner or loser and as defender of the public interest. While in both cases fiscal problems in the health systems are usually brought up in order to justify reform, the trigger for change in Israel has been the power contest between the two main parties--the Labor Party and the Likud Party--with the Likud attempting to impair the financial basis of the former. In Canada, the power contests are between the provinces and the federal government.     

Family caregivers: a shadow workforce in the geriatric health care system?

Based on two years of fieldwork, conducted between March 2003 and March 2005 in the health care industry of the northeastern United States, this study shows that the work of family caregivers of elders goes far beyond previously recognized care in the home to acknowledge care inside health care facilities and in conjunction with community services. It reveals that family caregivers--untrained, undersupported, and unseen--constitute a "shadow workforce," acting as geriatric case managers, medical record keepers, paramedics, and patient advocates to fill dangerous gaps in a system that is uncoordinated, fragmented, bureaucratic, and often depersonalized. Detailed examination of what family caregivers actually do in traversing multiple domains reveals the extent of their contribution to and the weaknesses in the present geriatric health care system. It suggests that the experiences of family caregivers must be central to the creation of new policies and a more coordinated system that uses the complex work of family caregivers by providing the training and support that they need.     

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.