Federalism and Health Care Cost Containment in Comparative Perspective

Despite widespread agreement over the connection between federalismand social expenditures during times of welfare state expansion,disagreement exists concerning federalism's role in the retrenchmentera. Existing approaches fail to recognize institutional variationamong federal states. Analysis of Britain, Germany, and Canadasuggests that federalism may promote or hinder health care retrenchmentdepending upon how it structures the relationship between regionaland national governments. Power-sharing federalism hinders healthcare reform by increasing the institutional obstacles to unpopularcutbacks. Power-separating federalism facilitates reform bycreating opportunities for blame avoidance without substantiallyincreasing the number of veto players. These findings challengetraditional linear or dichotomous models of federalism, suggestingthe need for an approach that captures how particular typesof federalism affect retrenchment politics.     

Welfare-State Expansion and Conflicts in the Nordic Countries: The Case of Occupational Health Care

The development of occupational health Services in the Nordic countries varied considerably in terms of coverage, content and conflicts during the period 1980–90. The focus is on differences in conflicts resulting from state intervention into the sphere of private employers analysed from three perspectives: policy ambitions, institutional arrangements and employer reaction. The main finding is that the high level of conflict in Norway is related to higher state ambitions, more fragmented institutions and more direct economic costs to the employers than those found in the other Nordic countries. The higher policy ambitions and resulting adversary processes in providing occupational health Services seem to be fundamentally rooted in specific egalitarian values inherent in the Norwegian welfare state in general and the trade union movement in particular.     

Vertical Competition in Unitary States: The Case of Italy

In unitary states – states in whichconstitutional powers are owned by thecentral government – vertical competitioncan generate stable outcomes, that isoutcomes that do not unravel througharbitrary repossessions by the center.Stability is a product of institutionalcommitment devices. Through these ademocratic government, though it cannotbind successor governments, can effectivelyoblige them to respect some of thedecisions it has made. A number of suchcommitment devices exist in Italy; theymake possible stable vertical competitionbetween central and regional governments.     

Local Pork-Barrel Politics in National Pre-Election Dates: The Case of Italy

Political representation in the national assemblies isgeographic and elected representatives care about whogains and who loses in their electoral districts. Since legislators are re-election oriented, theirchances of electoral success are directly associatedwith the net benefits delivered to their constituents. In this perspective, geography is not only the basisfor political organisation and representation, butalso the hallmark of distributive politics. In thiscontext, it is likely that locally elected politiciansand party leaders standing in national elections wouldtend to cooperate in pre-election dates. In thispaper we argue that local administrators have anincentive to manipulate local government outlays inconnection with national election dates to enhance there-election prospects of their national party leaders. In particular, given the matching character ofnational grants with local investment spending, weexpect that in pre-election dates local policy-makerswould be induced to raise investment outlays beyondtheir standard growth rate. This would determineinefficient local public spending as a result of thegeographically-based system of democraticrepresentation. The case study under our investigationis the behaviour of Italian local policy-makers inconnection with national election dates.     

Health Care Capital Financing Agencies: The Intergovernmental Roles of Quasi-Government Authorities and the Impact on the Cost of Capital

During the decade 1983-1992, approximately $1.4 trillion of municipal bonds were sold in 87,000 in separate issues, primarily to finance capital projects for education, electric power, transportation, health care, housing, and other public and private purpose activities. Approximately two-thirds of these financings were originated by financing authorities, quasi-government agencies which are the creation of state legislature. Despite the growing role played by quasi-public authorities in capital finance, their impacts have not been studied systematically. We first describe the issuers of tax-exempt debt in the health sector and then derive measures for describing the mix of issuers between state and local levels, and between both government and quasi-government sectors. We present abbreviated test results of the impact that different mixes have on the cost of capital. First, competition is good: using a Herfindahl index analysis we show that states with less concentrated issuers have a lower cost of capital than those with a more concentrated market, including state-level finance monopolies. On the other hand, we cannot assert unequivocally that market deconcentration, in and of itself, should be a goal. For instance, there are economies of scale in the health care finance industry that allow larger (often state-level) issuers to lower the cost of capital.     

Bureaucracy Versus Markets in Hospital Care: The Dutch Case

In this paper we analyze the bureaucratic negotiation processthat is implied by the budgeting system applied in Dutchhospital care. This system is based on centralized pricesetting while simultaneously allowing for decentralizednegotiations on volumes. We apply a variant of the bureaucracytheory, according to which the bureaucratic agency (in ourcase the joint hospitals) are not allowed to pricediscriminate, but will receive a flat price per unit ofoutput. We find that central price setting, where the insurercannot exploit its information on hospital costs, leads to asuboptimal supply of hospital care.     

'Designing Better Health Care in the South': A Case Study of Unsuccessful Transformational Change in Public Sector Health Service Reform

This article presents a case study of a project known as 'Designing Better Health Care in the South' that attempted to transform four separately incorporated health services in southern Adelaide into a single regional health service. The project's efforts are examined using Kotter's (1996) model of the preconditions for transformational change in organisations and the areas in which it met or failed to meet these preconditions are analysed, using results from an evaluation that was commenced during the course of the attempted reform. The article provides valuable insights into an attempted major change by four public sector health organisations and the facilitators and barriers to such change. It also examines the way in which forces beyond the control of individual public sector agencies can significantly impact on attempts to implement organisational change in response to an identified need. This case study offers a rare glimpse into the micro detail of health care reform processes that are so widespread in contemporary health services but which are rarely systematically evaluated.     

University Technology Transfer and Manufacturing Innovation: The Case of Italy

This article analyzes the influence of universities on Italian firms' probability to innovate. Using firm‐level data, we focus on institutionalized technology transfer (TT) activities in universities, namely spin‐offs, patents, and research contracts. Results show that TT activities play a significant role in the probability to innovate by Italian manufacturing firms located in the same province as the university. Nevertheless, the effect is not uniform: the contribution of university TT activities to the probability of firms' innovating is concentrated in certain territorial areas (North‐East and Center) and sectors (science based and scale intensive) and among firms that are large.     

The Changing Public-Private Infrastructure Mix: Economy-wide Implications

This article provides an economy-wide perspective on the changing role of the public sector in developing economic and social infrastructure in Australia. It analyses the scale and macroeconomic significance of the key economic and social infrastructure sectors — communication services, electricity, gas and water supply, transport, education, health and community services, government administration and defence. It then canvasses the major policy issues that have arisen in the progression from public to private infrastructure provision and considers why concerns about the trend fall in traditional public works spending may be misplaced in light of recent economic and institutional changes.     

Central-Local Government Relations in Transition: The Case of Swedish Child Care

The provision of subsidized child care has grown to become asizeable economic activity in Sweden during recent decades.This paper examines the changed financial relation betweencentral and local governments and the impact of child-caregrants on local government behaviour. We find that during anearlier regime, with a system of matching grants, localgovernments responded strongly to the incentives of the rules.This resulted in both intended and unintended outcomes, aswell as a distortion of information to the central government.Experiences from a recent transition of regime towards a kindof closed block grant system, illustrates new types ofadaptive behaviour but also the problem of finding a formulafor a fair allocation of resources among local governments.When designing a block grant system a distinction must be madebetween expenditures and resource needs; cost expenditure datado not necessarily reflect resource needs in cases where thereare national categorical equity goals related to socialservices of a merit-want character.     

Implementing Fiscal Decentralization: A Case Study of a Regional Tax Agency in Italy

As a measure to enhance the fiscal autonomy of the region, in 2006 the Regional Government of Sardinia in Italy decided to establish a tax agency for managing regional taxes on holiday houses and boat and aircraft transit. Based on interviews conducted with the tax agency director and staff, this article traces the trajectory and outcome of events included in the implementation of this part of the regional government's fiscal policy. Drawing from this case, this article theorizes the process of implementing fiscal decentralization by addressing the issue of how fiscal policy decisions affect the management of tax agencies in the start‐up stage. Social mechanisms of learning, brokerage, and actor certification provide important linkages between fiscal policy choices and organizational change. On the whole, the research argument made in this article further contributes to institutionalist and processualist research trends in current research on organization studies and public management.     

基于公共管理视角的全民免费医疗可持续性研究——以神木县医疗保障体系为例

医疗体制改革问题是现阶段我国政府公共管理中亟待解决的重要而迫切的问题之一.以陕西省神木县全民免费医疗保障体系为例,从公共管理的视角分析全民免费医疗模式的可持续性,可以为我国医疗体制改革的实践运作和理论研究提供重要的借鉴.     

The Health Care Safety Net and the Affordable Care Act: Implications for Hispanic Immigrants

There are currently more than 11 million undocumented immigrants in the United States; the majority of them are of Hispanic origin. This article shows that Hispanic immigrants in the Greater Richmond, Virginia, area rely heavily on free clinics for basic health care services. Free clinics do not receive any public funding and thus face reduced government regulation. As a result, these clinics typically present fewer barriers to undocumented immigrants seeking care. Although free clinics function outside the mainstream of government funding for health care services, the Patient Protection and Affordable Care Act (ACA) of 2010 is so broad and far‐reaching in its scope and potential application that free clinics cannot escape its grasp once the new law is fully implemented. Because the ACA does not provide insurance coverage to undocumented immigrants, free clinics will remain their primary sources of care and treatment. Consequently, those responsible for implementing the ACA should consider the impact on free clinics.     

Policy-making in a Restructured State: The Case of the 1991 Health Reform Policy in New Zealand

The pressure for efficiency and accountability that led to reform of public institutions worldwide has had implications for public policy-making as well as the management of public services. The difficulties of providing a coordinated and efficient policy process that can respond to the requirements of a more managerialist style of government were evident in New Zealand in the 1980s and early 1990s. The policy process in 1990–91 leading to the introduction of health reform proposals provides an illuminating case study of the tension between participation and speed, and between traditional pluralist and managerialist approaches to policy development. The implications of this for subsequent implementation are discussed.     

北京市城镇医药卫生体制改革研究报告

现行医药卫生体制存在卫生资源不合理,医疗费用增长过快,公立医疗机构缺乏活力,卫生资源利用效率不高,药品监管工作亟待加强等问题,针对以上问题,本提出了我市城镇医药卫生体制改革的主要内容与原则建议。