Playing fair: fairness beliefs and health policy preferences in the United States

Conventional wisdom suggests that the best way to persuade Americans to support changes in health care policy is to appeal to their self-interest - particularly to concerns about their economic and health security. An alternative strategy, framing problems in the health care system to emphasize inequalities, could also, however, mobilize public support for policy change by activating underlying attitudes about the unfairness or injustice of these inequalities. In this article, we draw on original data from a nationally representative survey to describe Americans' beliefs about fairness in the health domain, including their perceptions of the fairness of particular inequalities in health and health care. We then assess the influence of these fairness considerations on opinions about the appropriate role of private actors versus government in providing health insurance. Respondents believe inequalities in access to and quality of health care are more unfair than unequal health outcomes. Even after taking into account self-interest considerations and the other usual suspects driving policy opinions, perceptions of the unfairness of inequalities in health care strongly influence respondents' preferences for government provision of health insurance.     

Public health and human rights

The editorial introduces the special issue of the journal that incorporates papers originally presented at the "Public Health and Human Rights" conference held at the Monash Prato Centre, Italy, in June 2007. It identifies the intersection between public health and human rights; access to health care services, particularly for marginalised groups such as indigenous peoples and persons with mental illnesses; and the role of international instruments in encouraging states parties to implement and monitor compliance with these rights.     

Tackling the health divide in europe: the role of the world health organization

Europe faces major health challenges in addition to its well-reported economic and financial difficulties. Despite the overall improvement in population health, significant inequalities remain, with a growing gap between rich and poor. WHO Europe, covering fifty-three member states, is committed to helping European governments meet the complex challenge posed by the "silent epidemic" of noncommunicable diseases. In September 2012 WHO launched Health 2020, an ambitious new health policy framework and strategy. Its success requires a whole-of-government and whole-of-society approach to improving health and well-being, informed by the latest evidence on cost-effective interventions. This review considers the prospects for success.     

An Exploration of Conceptual and Temporal Fallacies in International Health Law and Promotion of Global Public Health Preparedness

In February 2007, Indonesia withheld sharing H5N1 viral samples in order to compel the World Health Organization and Member States to guarantee future access to vaccines for States disproportionately burdened by infectious diseases. This article explores conceptual and temporal fallacies in the International Health Regulations (2005) and the Doha Declaration on the TRIPS Agreement and Public Health, as relates to global public health preparedness. Recommendations include adopting laws to facilitate non-pharmaceutical interventions; securing the rights of affected populations; and fostering inter-State collaborations to promote intra-State public health capacity building.     

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.     

Health care for older persons in England and the United States: a contrast of systems and values

This article extends previous comparisons of access to health care for older persons in England and the United States by comparing rates of avoidable hospital conditions as a proxy for primary care access and by examining the distribution of care within these older populations. Drawing on hospital data from the two countries, we find that older persons in the United States, particularly those over the age of seventy-five, receive far more revascularizations than do older persons in England. Differences in the use of lower-joint replacement are not as great, but we are unable to assess differences in the need for these procedures. Although older persons have greater access to specialty care in the United States, there appears to be much better access to primary care in England. We are unable to draw comparisons on the extent of inequalities in access to health care, although in the United States there is evidence of inequalities in access by race, and in England we confirm earlier studies that find inequalities by level of deprivation. These findings are discussed in the context of the political debates over access to care and rationing in the two countries.     

重大突发公共卫生事件中防疫用品市场管制理路

作为一种公共干预,管制通常是对经济事件或市场失灵的特殊回应。重大突发公共卫生事件中防疫用品市场管制基础在于防疫用品的公共性和外部性。管制必须于法有据,这就需要以相应的管制立法为前提。为有效化解法律稳定性与重大突发公共卫生事件应对所要求的及时性、灵活性的矛盾,政府需要着眼于供给和需求两端,立足防疫用品生产、销售、消费三个环节,依据相关立法遵循法定程序,出台相应的管制政策。     

Redefining mental health law

Mental health law traditionally focuses on preserving the civil and constitutional rights of people labeled mentally ill. However, because of fundamental changes in the public mental health system. most people labeled mentally ill no longer reside in state psychiatric hospitals. As a result, the core policy issue in mental health today is assuring access to community based services, supports, and housing which enable people to live successfully in the community. Because of this different environment, the definition and scope of mental health law must be expanded dramatically if those interested in the subject are to continue to influence mental health policy. This article examines five contemporary mental health policy issues, including changes in reimbursement systems and the growth of the consumer and family movements, that illustrate the legal, policy, and research questions which will emerge in an expanded and redefined mental health law agenda. The author thanks Ingo Keilitz, Thomas Hafemeister, and Pamela Casey for their review of earlier drafts of this article.     

Will physician unions improve health system performance?

In the public debate over the extension of collective bargaining rights to independent physicians, union proponents' primary argument has been that patients would benefit from allowing physicians to bargain collectively with health plans. This article examines the likely effects of physician unions on the U.S. health care system. Specifically considered are likely effects on economic efficiency, quality, access, and cost. Under none of these criteria are physician unions likely to improve health system performance, particularly when compared with available alternative strategies for dealing with problems identified by union proponents.     

疫情防控:经济法的解析与应对

疫情防控是对国家治理体系和治理能力的重大考验,需要政策与法律的协调并用;疫情防控作为复杂的系统工程,离不开多种法律制度的综合调整,其中经济法的作用尤为重要。运用经济法的“两个失灵”理论、风险理论、信息理论和价值理论,有助于解析疫情的成因及其预防,明晰疫情防控的必要性、重要路径和价值引领,从而可以有针对性地进行制度应对;疫情防控需要宏观调控法和市场规制法的大量运用,应将重要的发展理念和法治理念贯穿其中,从而形成“依法治疫”的制度体系。基于“以人为本”的“依法治疫”,有助于防止疫情的暴发和扩散,减少公共卫生危机的发生及其给社会、经济造成的巨大损害,从而能够在保障公众生命健康的前提下,促进经济与社会的良性运行和协调发展。     

HIV/AIDS legal issues in the United States

The HIV/AIDS epidemic continues to be a leading public health issue in the United States. During the past decade, the epidemic has shifted away from the gay community, although gay and bisexual men continue to be the largest single HIV exposure category. Now, HIV increasingly affects low-income people of colour in urban areas, as well as women. As AIDS becomes more and more a minority, inner-city disease, public focus on the epidemic as a significant social and political issue is waning. While a full survey of current issues in US law is beyond the scope of this article, the focus here is on current issues that are highly relevant to the direction the epidemic appears to be taking.     

Advancing Health Rights in a Globalized World: Responding to Globalization through a Collective Human Right to Public Health

The right to health was codified in Article 12 of the International Covenant on Economic, Social and Cultural Rights as an individual right, focusing on individual health services at the expense of public health systems. This article assesses the ways in which the individual human right to health has evolved to meet collective threats to the public's health. Despite its repeated expansions, the individual right to health remains normatively incapable of addressing the injurious societal ramifcations of economic globalization, advancing individual rights to alleviate collective inequalities in underlying determinants of health. By examining modern changes to underlying determinants of health, this article concludes that responding to globalized health threats necessitates a collective right to public health.     

A consideration of user financial incentives to address health inequalities

Health inequalities and user financial incentives to encourage health-related behavior change are two topical issues in the health policy discourse, and this article attempts to combine the two; namely, we try to address whether the latter can be used to reduce the former in the contexts of the United Kingdom and the United States. Payments for some aspects of medical adherence may offer a promising way to address, to some extent, inequalities in health and health care in both countries. However, payments for more sustained behavior change, such as that associated with smoking cessation and weight loss, have thus far shown little long-term effect, although more research that tests the effectiveness of different incentive mechanism designs, informed by the findings of behavioral economics, ought to be undertaken. Many practical, political, ethical, and ideological objections can be waged against user financial incentives in health, and this article reviews a number of them, but the justifiability of and limits to these incentives require more academic and public discourse so as to gain a better understanding of the circumstances in which they can legitimately be used.     

Making the best of hard times: how the nation's economic circumstances shaped the public's embrace of health care reform

The U.S. Congress enacted expansive (and expensive) health care reforms amid the worst economic downturn since the Great Depression. Public acquiescence provided crucial political cover; elites on both sides struggled mightily to sway popular opinion. Were reformers' efforts made easier or more difficult by the tough economic times? Using newly available data on Americans' perceptions of economic insecurity and attitudes toward public policy, this article explores the relationship between economic circumstances and political attitudes. The findings suggest that the Great Recession both facilitated and impeded efforts to rally the public in favor of reform: perceptions of past declines in the U.S. economy bolstered government intervention, but household economic insecurity both distracted attention from large medical expenses (which otherwise legitimized collective action) and undermined Americans' support for additional government spending. Equally consequential, reformers' efforts to adapt to economic stringency by portraying reform as exclusively about affordability missed opportunities for broadening popular support for these interventions; in the longer run this may, unless corrected, prove a decisive misstep in shepherding the Patient Protection and Affordable Care Act through its long time line of implementation.     

Weighing both sides: morality, mortality, and framing contests over obesity

Despite recent and growing media attention surrounding obesity in the United States, the so-called obesity epidemic remains a highly contested scientific and social fact. This article examines the contemporary obesity debate through systematic examination of the claims and claimants involved in the controversy. We argue that four primary groups-antiobesity researchers, antiobesity activists, fat acceptance researchers, and fat acceptance activists-are at the forefront of this controversy and that these groups are fundamentally engaged in framing contests over the nature and consequences of excess body weight. While members of the fat acceptance groups embrace a body diversity frame, presenting fatness as a natural and largely inevitable form of diversity, members of the antiobesity camp frame higher weights as risky behavior akin to smoking, implying that body weight is under personal control and that people have a moral and medical responsibility to manage their weight. Both groups sometimes frame obesity as an illness, which limits blame by suggesting that weight is biologically or genetically determined but simultaneously stigmatizes fat bodies as diseased. While the antiobesity camp frames obesity as an epidemic to increase public attention, fat acceptance activists argue that concern over obesity is distracting attention from a host of more important health issues for fat Americans. We examine the strategies claimants use to establish their own credibility or discredit their opponents, and explain how the fat acceptance movement has exploited structural opportunities and cultural resources created by AIDS activism and feminism to wield some influence over U.S. public health approaches. We conclude that notions of morality play a central role in the controversy over obesity, as in many medical disputes, and illustrate how medical arguments about body weight can be used to stymie rights claims and justify morality-based fears.     

The right to health in public health: is this a new approach?

The international human rights community has frequently reaffirmed the importance of full respect for the right to health. However, there remains a large gap between the standards set out in Art 12 of the International Covenant on Economic, Social and Cultural Rights and the situation prevailing in most countries. While there has been a substantial amount of work done to expand upon the content of the right to health, there has been little consideration of what a right to health means for public health programming generally. This article addresses this issue by considering the compatibility of the essential elements of contemporary public health programming practice with the principles contained in General Comment No 14, para 43(f) (a minimum core obligation of the right to health). The article considers that while both contemporary public health practice and para 43(f) do contain compatible elements, the right to health brings with it new elements of monitoring (through right to health indicators) and accountability, both of which will require new tools to be adopted by the public health sector.     

Interpreters of International Economic Law: Corporations and Bureaucrats in Contest over Chile's Nutrition Label

This article analyzes the everyday interpretive practices of corporations and bureaucrats that shape the meaning and force of international economic law. To understand how common practices such as public consultation submissions, corporate threat letters, and external legal assistance influence regulators' understanding of their “legally available” policy space, we study the contested introduction of a pioneering nutrition labeling regulation in Chile. The transnational food industry powerfully challenged the regulation's legality under World Trade Organization law. But Chilean health bureaucrats, in coordination with segments of the country's legally highly competent economic bureaucracy, effectively defended the legality of their proposed regulatory measure. Drawing on data from freedom-of-information requests and in-depth interviews, the article argues that the outcomes of such interpretive contests are substantially shaped by participants' knowledge of the entitlements created by international economic law and thus by the international legal expertise they have access to. This often but not always puts transnational corporations at an advantage over national regulators in the strategic interpretation of international economic law.     

Streetwork at the crossroads: An evaluation of a street gang outreach intervention and holistic appraisal of the research evidence

Spurred by the success of public health violence interventions, and accelerated by policy pressure to reduce violence without exacerbating overpolicing and mass incarceration, streetwork programs—those that provide anti-violence services by neighborhood-based workers who perform their work beyond the walls of parochial institutions—have positioned themselves as the most important non–law-enforcement violence prevention option available to urban policy makers. Yet despite their importance, the state of the field seems difficult to interpret for academics and practitioners alike. In this article, we make several contributions that bring forth new findings and deliver new perspectives on streetwork as a violence reduction strategy. First, we offer an extended analytic review of the streetwork evaluation literature that connects the study of contemporary public health violence interventions to a preceding tradition of criminologically inspired streetwork studies. Second, we present the results of an impact evaluation of StreetSafe Boston (SSB)—a multiyear streetwork intervention that served 20 Boston gangs. We find that the SSB intervention had no detectable effect on violence among the gangs that it served. We conclude by offering a framework for understanding a field at multiple crossroads: past and present, proclaimed successes and failures, help and harm.     

PERSONS WITH DISABILITIES AND THEIR SEXUAL,REPRODUCTIVE, AND PARENTING RIGHTS: AN INTERNATIONAL AND COMPARATIVE ANALYSIS

Despite important gains in human rights, persons with disabilities — and in particular women and girls with disabilities — continue to experience significant inequalities in the areas of sexual, reproductive, and parenting rights. Persons with disabilities are sterilized at alarming rates; have decreased access to reproductive health care services and information; and experience denial of parenthood. Precipitating these inequities are substantial and instantiated stereotypes of persons with disabilities as either asexual or unable to engage in sexual or reproductive activities, and as incapable of performing parental duties. The article begins with an overview of sexual, reproductive, and parenting rights regarding persons with disabilities. Because most formal adjudications of these related rights have centered on the issue of sterilization, the article analyzes commonly presented rationales used to justify these procedures over time and across jurisdictions. Next, the article examines the Convention on the Rights of Persons with Disabilities and the attendant obligations of States Parties regarding rights to personal integrity, access to reproductive health care services and information, parenting, and the exercise of legal capacity. Finally, the article highlights fundamental and complex issues requiring future research and consideration.     

Chronic disease and the shifting focus of public health: is prevention still a political lightweight?

Why is it so politically difficult to obtain government investment in public health initiatives that are aimed at addressing chronic disease? This article examines the structural disadvantage faced by those who advocate for public health policies and practices to reduce chronic disease related to people's unhealthy lifestyles and physical environments. It identifies common features that make it difficult to establish and maintain initiatives to prevent or reduce costly illness and physical suffering: (1) public health benefits are generally dispersed and delayed; (2) benefactors of public health are generally unknown and taken for granted; (3) the costs of many public health initiatives are concentrated and generate opposition from those who would pay them; and (4) public health often clashes with moral values or social norms. The article concludes by discussing the importance of a new paradigm, "health in all policies," that targets the enormous health and economic burdens associated with chronic conditions and asserts a need for new policies, practices, and participation beyond the confines of traditional public health agencies and services.