Another special relationship? Interactions between health technology policies and health care systems in the United States and the United Kingdom

Confronted with similar challenges, the United States and the United Kingdom have adopted very different health technology policies. In the United States, the focus has been on technology creation, in particular the funding of basic biomedical research at the National Institutes of Health. This both reflects and reinforces an innovation-first culture in the United States, including in health. By contrast, the United Kingdom has been much more heavily committed to applied research and evaluative research, including health-technology assessment. That is, while U.S. policy has focused on technology creation, U.K. policy has been more oriented toward technology diffusion. This article surveys the sources of these differences. We consider the impacts of institutional, cultural, and other factors that may explain them, and emphasize that it is hard to disentangle the separate effects of those factors. We conclude with a discussion of the difficulties in drawing cross-national lessons in health technology policy.     

The fox and the grapes: is real reform beyond reach in the United States?

As the challenges of maintaining (or, in the US case, attaining) affordable universal coverage multiply, the debate about what constitutes "real" reform intensifies in Western health care systems. The reality of reform, however, lies in the eyes of myriad beholders who variously enshrine consumer responsibility, changes in payment systems, reorganization, and other strategies -- or some encompassing combination of all of the above -- as the essential ingredient(s). This debate, increasingly informed by the agendas of health services researchers and health policy analysts, arguably serves as much or more to becloud as to clarify the practical options policy makers face and remains severely imbalanced with respect to the institutional sectors on which it concentrates, the fields of knowledge on which it draws, and the roles it envisions for markets and the state.     

Does racism affect health? Evidence from the United States and the United Kingdom

Blacks have worse overall health than whites in both the United States and the United Kingdom. However, the relative difference in health between the two groups within each cultural context differs between each context. In this article, we attempt to glean insights into these health disparities. We do so by first examining what is currently known about differences in morbidity and mortality for blacks and whites in the United States and the United Kingdom. We then turn to medical examination data by race and country of birth in an attempt to further untangle the complex interplay of socioeconomic status (SES), race, and racism as determinants of health in the United States and the United Kingdom. We find that (1) longer exposure of blacks to the recipient country is a risk for mortality in the United States but not in the United Kingdom; (2) adjustment for SES matters a good deal for mortality in the United States, but less so in the United Kingdom; (3) morbidity indicators do not paint a clear picture of black disadvantage relative to whites in either context; and (4) were one to consider medical examination data alone, differences between the two groups exist only in the United States. Taken together, we conclude that it is possible that the "less racist" United Kingdom provides a healthier environment for blacks than the United States. However, there remain many mysteries that escape simple explanation. Our findings raise more questions than they answer, and the health risks and health status of blacks in the United States are much more complex than previously thought.     

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.     

Why hasn't integrated health care developed widely in the United States and not at all in England?

There have been influential advocates for financing and organizing health care in the United States and England based on the model of integrated health care delivery systems (IHCDSs). Despite good evidence that a few IHCDSs provide high-quality health care economically, such organizations are rare and localized in a few market areas in the United States and are absent in the English National Health Service (NHS). The explanation of why this is so includes various contributory factors: the way the development of the medical profession in each country pursued specialization; the division in British medicine between general practitioners and specialists; and the characteristics that we identify of established successful IHCDSs, which created formidable barriers to entry for a new IHCDS. This explains why currently the most promising organizational developments in U.S. health care are hybrids resulting from vertical integration. In England government policies of an "internal market," as adopted in the 1990s and currently, were and are based on a purchaser-provider split with the objectives that providers would compete and be funded by a system in which "money follows the patient." These policies recognize the division in British medicine, which also means that it is difficult to implement a reorganized English NHS based on high-performing IHCDSs.     

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.     

Back to the future? Health benefits, organized labor, and universal health care

The umbrella of employment-based health benefits is growing increasingly threadbare. As a result, health benefits are once again a major arena of labor-management strife, and once again calls for universal health care by many labor leaders mask important differences between them over health care reform. Some labor leaders advocate a bottom-up mobilization in support of a single-payer solution that would dismantle the system of job-based benefits rooted in private insurance. Others stake their health care strategy on wooing key business leaders to be constructive partners in some kind of unspecified comprehensive reform of the health system. Organized labor faces enormous obstacles, both institutional and ideological, to forging an effective united front to fight for comprehensive, high-quality, affordable health care for all. Two entrenched features of the shadow welfare state of job-based benefits, notably the Employee Retirement Income Security Act (ERISA) of 1974 and the union-run health and welfare funds created under the Taft-Hartley Act, remain daunting barriers on the road to reform, exacerbating tensions and differences within organized labor. Moreover, a dramatic ideological schism in the labor movement about its future direction vexes its stance on health care reform. These ideological differences fuel vastly different views within organized labor about how best to confront the unraveling of job-based health benefits and the growing popularity among business leaders, insurers, and public officials of the "individual-mandate" solution, which would penalize people who do not have adequate health insurance.