Rationing psychosocial treatments in the United States

This paper briefly reviews the recent history of psychosocial treatment for adults with severe mental illnesses in the United States. It examines the current sources and financing of such care, revealing the planned and unplanned reclassification of entitled beneficiaries and eligible patients, appropriate treatment, acceptable outcomes, and levels and sources of payment. One illustration of this phenomenon is seen in current efforts to identify and deliver only those public services that are covered by Medicaid, so as to allocate state resources only when they can be matched by federal monies. Another is the reliance on private health insurance, tied in the U.S. almost exclusively to employment, for medical care delivered under an acute, rather than a chronic care model. These analyses conclude with a discussion of the implicit and explicit mechanisms used to ration access to psychosocial treatment in the United States. The implications for individuals with serious mental illnesses, their families, and the general public are placed in historical and current policy contexts, recognizing the economic, social, and clinical variables that can moderate outcomes.     

The political and economic context of mental health care in the United States

Since the mid-1970s, the mental health treatment system in the U.S. has faced budgetary famine. This is in stark contrast to the growing cornucopia of fiscal resources enjoyed by the overall health care system. This paper explores the complex reasons for this disproportionate allocation in health spending. On the one hand, mental health may suffer from the perception that its diagnoses are largely "subjective" and its treatments do not fit the traditional "medical model" that can be defined precisely and paid for by third-party insurers. But more importantly, the death of mental health resources can be attributed to the peculiar nature and characteristics inherent in American politics. This paper describes the American political environment, from both a historical and a contemporary perspective, to give some insight into the development of policies affecting the mental health system in the U.S. Given the current climate of fiscal conservatism in this country toward any increases in social spending, it is likely that the profound mismatch in need and spending for mental health programs will continue indefinitely.     

The constitutionality of current legal barriers to telemedicine in the United States: analysis and future directions of its relationship to national and international health care reform

The current health care crisis in the United States compels a consideration of the crucial role that telemedicine could play towards deploying a pragmatic solution. The nation faces rising costs and difficulties in access to and quality of medical services. Telemedicine can potentially help to overcome these challenges, as it can provide new cost-effective and efficient methods of delivering health care across geographic distances. The full benefits and future potential of telemedicine, however, are constrained by overlapping, inconsistent, and inadequate legal and regulatory frameworks, as well as the repertoire of standards imposed by state governments and professional organizations. Proponents of these barriers claim that they are necessary to protect public health and safety, and that the U.S. Constitution gives states exclusive authority over health and safety concerns. This Article argues that such barriers not only fail to advance these public policy goals, but are unconstitutional when they restrict the practice of telemedicine across state and national borders. Furthermore, the interstate and international nature of telemedicine calls for increasing the centralized authority of the federal government; this position is consistent with the U.S. Constitution and other governing principles. Finally, this Article observes that the U.S. experience bears some similarities to that of other nations, and represents a microcosm of the international community's need and struggle to develop a uniform telemedicine regime. Just as with state governments in the U.S., nations are no longer able to view health care as a traditional domestic concern and must consider nontraditional options to resolve the dilemmas of rising costs and discontent in the delivery of health care to their people.     

The Use and Misuse of 'National Security' Rationale in Crafting U.S. Refugee and Immigration Policies

Since the terrorist attacks of 11 September 2001, U.S. immigrationand refugee policy has developed based on narrow and evolvingtheories of ‘national security’. Immigration reformlegislation, federal regulations, and administrative policychanges have been justified in terms of the nation's safety.On 1 March 2003, the U.S. Immigration and Naturalization Service(INS) was folded into the massive new U.S. Department of HomelandSecurity (DHS), formally making immigration a homeland defenseconcern. Counterterror and immigration experts increasingly agree onwhat constitute effective and appropriate immigration policyreforms in light of the terrorist threat. Unfortunately, manyof the post-September 11 policy changes do little to advancepublic safety and violate the rights of refugees and asylumseekers. These include reductions in refugee admissions, thecriminal prosecution of asylum seekers, the blanket detentionof Haitians, and a safe third-country asylum agreement betweenthe United States and Canada. Other measures offend basic rightsand may undermine counterterror efforts. These include ‘preventive’arrests, closed deportation proceedings, and ‘call-in’registration programs. This article reviews post-September 11 U.S. policy developmentsbased on their impact on migrant rights and their efficacy ascounterterror measures. It argues for a more nuanced and rigoroussense of ‘national security’ in crafting refugeeand immigration policy.     

National Treasure: Implicit Protections of Cultural Property in the United States

Despite the international prevalence of cultural export controls, the United States has not adopted explicit measures for that purpose. Whereas many culture-rich nations have found it necessary to implement explicit export controls to stem an exodus of prominent works of culture, U.S. common law and national policy, by relying on traditional concepts of property ownership rights and charity, have achieved similar effects without placing undue limits on international trade. In this article, I posit that any change in the current approach and toward explicit export control would be inimical to the U.S. self-interest and the developmental direction of the relevant legal policy.     

Eligibility for health care benefits for certain Filipino veterans in the United States. Final rule

Department of Veterans Affairs (VA) medical regulations describe veterans who are eligible to receive health care from VA in the United States. This document amends VA medical regulations to provide eligibility for VA hospital care, nursing home care, and outpatient services for any Filipino Commonwealth Army veteran, including those recognized by authority of the U.S. Army as belonging to organized Filipino guerilla forces, and for any veteran of the new Philippine Scouts, provided that any such veteran resides in the U.S. and is either a citizen of the U.S. or is lawfully admitted to the United States for permanent residence. Under this regulatory provision, these certain veterans are eligible for VA hospital care, nursing home care, and outpatient medical services in the United States in the same manner and subject to the same terms and conditions as apply to U.S. veterans.     

National Party Efforts to Recruit State Legislators to Run for the U.S. House

We explore factors that influence the chances that a state legislator will be the target of national party recruitment to run for the U.S. House. Using data from a sample of legislators in 200 U.S. House districts, we find that national party contact reflects strategic considerations of party interests. State legislators serving in professional institutions and in competitive districts are most likely to be contacted by national party leaders. In addition, the analysis suggests that national party leaders may be sensitive to the potential costs to the state legislative party: legislators in institutions that are closely balanced between the parties are slightly less likely to be contacted.     

HMO promotion and the privatization of health care in Chile

Since 1973 the Chilean junta has privatized sectors of the national economy. This paper analyzes the country's policy process of promoting private medical programs through HMO-like plans (ISAPREs, or Institutes of Provisional Health). These plans have captured less than half of their originally anticipated market share. It is argued that the future performance of ISAPREs will be undermined by their limited maternal benefits, their targeting to a small upper-income group which cannot sustain many private medical programs, and competition with less expensive yet equally competent public medical programs. The paper briefly compares privatization in Chile with the experiences of other countries, and specifically contrasts the restructuring of health services under military rule in Chile with those of Argentina and Uruguay. The paper concludes that the Chilean experience with HMOs epitomizes the perils of planning health care during short-term periods of economic prosperity as well as failing to consult medical care providers and consumers.     

An end to a consensus on health care in the Federal Republic of Germany?

Over the past fifteen years the national government in the Federal Republic of Germany has animated the political debate about rising health care expenditures. However, it has only provided health policy leadership by shifting the burden of financing health and medical care to others. This paper presents three cases that illustrate the political and institutional constraints inherent in the German policy process that limit the proposal and implementation of appropriate policy solutions to rising health care costs. Cost controls have been inhibited because of the near-universal entitlement of national health insurance, the access all social groups have to advanced medical care, and policies targeted at providers rather than users of health services. The paper also underscores the past and future importance of regional policy coalitions in shaping national health policy.     

美国联邦政府的煤矿安全生产监管制度研究

中美两国都是世界上最主的煤炭生产国和消费国.但是,两国的煤矿安全状况却存在较大差异.除了煤炭产业结构、技术水平和资源禀赋等因素之外,煤矿安全监管法治建设也是导致这一差异的重原因.美国煤矿安全生产立法经历多轮修订,不断纠正历次重大煤矿事故暴露出的监管缺陷,建立起独立高效的煤矿安全监管体系,完善煤矿安全监察和事故调查程序,优化了法律责任和执法机制.此外,煤矿安全监察员和煤矿从业人员的强制培训制度,也可以有效加强监管机构的监管能力和监管对象的合规水平.而美国矿山安全和健康委员会独立负责的行政复议,有效保障了对行政执法行为的纠错和对相对人的救济功能.这些经验值得中国参考借鉴.     

Reform and the politics of hybridization in mature health care states

This article examines the cases of three health care states -- two of which (Britain and the Netherlands) have undergone major policy reform and one of which (Canada) has experienced only marginal adjustments. The British and Dutch reforms have variously altered the balance of power, the mix of instruments of control, and the organizing principles. As a result, mature systems representing the ideal-typical health care state categories of national health systems and social insurance (Britain and the Netherlands, respectively) were transformed into distinctive national hybrids. These processes have involved a politics of redesign that differs from the politics of earlier phases of establishment and retrenchment. In particular, the redesign phase is marked by the activity of institutional entrepreneurs who exploit specific opportunities afforded by public programs to combine public and private resources in innovative organizational arrangements. Canada stands as a counterpoint: no window of opportunity for major change occurred, and the bilateral monopoly created by its prototypical single-payer model provided few footholds for entrepreneurial activity. The increased significance of institutional entrepreneurs gives greater urgency to one of the central projects of health policy: the design of accountability frameworks to allow for an assessment of performance against objectives.     

Physicians' conflicts of interest in Japan and the United States: lessons for the United States

Japanese health policy shows that even with physician ownership and the absence of for-profit, investor-owned health care, physicians' conflicts of interest thrive. Physician dispensing of drugs and ownership of hospitals and clinics were justified in Japan as ways to avoid commercialization of medicine. Instead, they create physicians' conflicts and fuel patient overuse of services. Japan's Ministry of Health and Welfare (MHW) has responded by introducing per-diem payment, thereby creating incentives to decrease services in ways similar to those of American managed care organizations, but with none of their benefits, such as coordination of care, oversight of physicians practices, and quality assurance. Although the United States and Japanese health care systems are organized and financed differently there is convergence in the source of their physicians' conflicts and the way they are addressed. The United States is starting to integrate institutional and physician payment and align their incentives, in a traditional Japanese way. In so doing, the United States creates new physicians' conflicts and reduces the role of countervailing incentives and power, an advantage of previous policy. Japan, in turn, has combined incentives to increase and decrease services, thus moving closer to the U.S. policy.     

The form and context of federalism: meanings for health care financing

This article examines the meaning of federalism for health care financing (HCF) and is based on two considerations. First, federal institutions are embedded in their national context and interact with them. The design and performance of HCF policy will be influenced by contexts, the workings of the federal institutions, and the interactions of these institutions with different elements of the context. This article unravels these influences. Second, there is no unique model of federalism, and so we have to specify the particular form to which we refer. The examination of the influence of federalism and its context on HCF policy is facilitated by using a transnational comparative approach, and this article examines four mature federations: the United States, Australia, Canada, and Germany. The relatively poor performance of the U.S. HCF system seems associated with the fact that it operates in a context markedly less benign than those of the other national HCF systems. Heterogeneity of context appears also to have contributed to important differences between the United States and the other countries in the design of HCF policies. An analysis of how federalism works in practice suggests that, while U.S. federalism may be overall less favorable to the development of well-functioning HCF policies, the inferior performance of these policies is to be principally attributed to context.     

Hidden convergence: toward a historical comparison of U.S. and U.K. health policy

The social science literature on the comparative history of the welfare state offers conflicting accounts of the relationship between the United States and the United Kingdom. At first blush, the comparative history of health care policy in the United States and the United Kingdom seems to affirm the dominant view that the U.S. and U.K. welfare states have diverged substantially during the twentieth century. A comparison of U.S. and U.K. health policy, however, suggests that there are more parallels and points of tangency between the two systems than are readily apparent. The comparative history of health policy over the past century reveals common political and policy challenges and frequent interchanges of policy ideas, and helps uncover the political dynamics behind the development of health policy in the two countries, which can, in turn, help illuminate the contemporary politics of reform in both countries.     

The Teaching of Denture Marking Methods in Dental Schools in the United Kingdom and the United States*,†

Abstract: Forensic organizations worldwide have recommended that dental prostheses should be marked with, at a minimum, the patient’s name and preferably with further unique identifiers such as a social security number. The current study aimed to assess the denture marking practice of dental schools within the United States and the United Kingdom. A questionnaire‐based survey was employed to gain both quantitative and qualitative data on the methods, practices, and ethos behind denture marking in 14 U.K. and 32 U.S. dental schools. One hundred percent of U.K. and 87.5% of U.S. schools returned surveys and the results suggest that, for dental schools where there is no legal or legislative need for denture marking, the practice is inconsistently taught and appears to be reliant on internal forces within the school to increase awareness. Among those schools practicing marking, only 18% employ a technique likely to withstand common postmortem assaults; this is a concern.     

Child health policy in the U.S.: the paradox of consensus

The U.S. spends more of its total GNP on health services than any other nation, yet it has one of the highest infant mortality rates in the industrialized world. Young American children are immunized at rates that are one-half those of Western Europe, Canada, and Israel. In the mid-1980s, a consensus among policymakers on the need for federal action to improve child health services resulted in the expansion of Medicaid eligibility for pregnant women and young children and the separation of Medicaid eligibility from eligibility for AFDC. The current phase of child health policymaking includes discussion of much broader proposals for changes in health care financing and innovation in health care delivery. This examination of child health policy begins by reviewing the politics of maternal and child health services from the early twentieth century to the Reagan administration, including the role of feminist movements, the development of pediatrics, and the expansion of federal involvement during the 1960s. Next, the politics of Medicaid expansion as a strategy for addressing child health issues are discussed. Current critiques of child health services in the U.S. are examined, along with proposals to restructure health care financing and delivery. Central to the politics of child health policy during the 1980s and into the 1990s is the way in which child health has been defined. Infant mortality and childhood illness are presented as preventable problems. Investment in young children is discussed as a prudent as well as a compassionate policy, one which will reduce future health care costs and enhance our position in the international economy. Unlike other "disadvantaged groups," children are universally viewed as innocent and deserving of societal support. Framing child health issues in these terms helped to produce consensus on the expansion of Medicaid eligibility. Yet the issues beyond the expansion of Medicaid eligibility involve the restructuring of health care financing and delivery, and, on these issues, conflict is far more likely than consensus.     

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.     

Measuring the performance of research and technology programs: A balanced scorecard approach

Research programs, like other government programs, are now being requested to demonstrate relevance and value added to national social and economic needs. Complexity, unpredictability and other factors make it difficult to define specific performance measures for R&D programs. This paper describes the performance measurement efforts of one technology development program within the U.S. Department of Energy and proposes a strategy for applying this balanced scorecard approach to a fundamental research organization. Simple logical models of the inputs, activities, outcomes and long term results of R&D programs are proposed. A critical few measures of performance that answer questions from multiple audiences are then chosen across this performance spectrum. This paper describes work performed by Sandia National Laboratories Energy Policy and Planning Department, Albuquerque, New Mexico 87185, with the support of the U.S. Department of Energy under contract DE-AC0494AL85000. The continued support and enthusiams of Darrell Beschen in the DOE Office of Energy Efficiency and Renewable Energy and Iran Thomas in DOE Office of Energy Research, Basic Energy Sciences, is appreciated. The authors also acknowledge the contributions of John Reed and the training in the logic chart and performance spectrum provided by Ron Corbeil and Steve Montague. The opinions expressed are those of the authors and do not represent the opinions of the U.S. Department of Energy.