The role of group interest,identity, and stigma in determining mental health policy preferences

Public attitudes toward mental health present an interesting puzzle. While mental health is one aspect of general health and well-being, it receives less support for government spending increases than does health care. One explanation lies with the stigma that is attached to mental illness. This stigma produces more negative attitudes on policy issues related to persons with mental illness such as government spending for mental health. However, group identification, as defined by personal experience or a family member who has experienced a mental illness, may have a strong effect on these attitudes. Using data from the 1996 General Social Survey's module on mental health. I examine this and other hypotheses and find evidence that group identification increases the likelihood of increased support for government spending for mental health. These robust findings exist even in quantitative models, which include politically relevant variables and measure identification with mental illness in two different ways. These findings suggest that mental health is policy for the few because those most supportive of government spending increases are persons who share the common identity of experiencing mental illness.     

Federal influence on state health policy

This paper reports on research that was intended to demonstrate the impact of federal programs on state health policy goals. The sample included four Public Health Service programs (Health Planning and Resources Development, Nurse Training, Cooperative Health Statistics and the Community Mental Health Centers program) in six states (Colorado, Maryland, Michigan, Oregon, South Carolina, and Texas). The authors conclude that, in general, states' political environments tailor program implementation to suit state preferences.     

State legislative staff influence in health policy making

State legislative staff may influence health policy by gathering intelligence, setting the agenda, and shaping the legislative proposals. But they may also be stymied in their roles by such institutional constraints as hiring practices and by turnover in committee leadership in the legislature. The intervening variable of trust between legislators and their support staff is also key to understanding influence and helps explain how staff-legislator relationships play an important role in designing state health policy. This study of legislative fiscal and health policy committee staff uses data from interviews with key actors in five states to model the factors important in explaining variation in the influence of committee staff on health policy.     

Health policy and ERISA: interest groups and semipreemption

This paper is a history of the health policy results of the Employee Retirement and Income Security Act of 1974, particularly section 514, which preempts state laws "which relate to any employee benefit plan" but permits states to continue to regulate the business of insurance. This history exemplifies how health policy is often made outside conventional arenas. On the basis of published primary sources and interviews with a number of key participants, the paper describes how interest groups which rarely act together coalesced to create and sustain semipreemption and its effects on state and federal health policy. The paper concludes with an assessment of recent state legislative efforts to address the problems created by ERISA semipreemption. The ironical results of semipreemption occurred because of the absence of a coalition of interest groups that was sufficiently strong to resolve the fundamental questions raised by our commitment to linking health insurance to employment.     

Immigrant workers: health, law, and public policy

Immigrant workers are a large segment of the lower echelon of the U.S. labor force, and as many as 3.6 to 6 million of these workers and their families are living in the U.S. illegally. This paper examines who the recent immigrants are: explains why their current situation in the U.S. is an important public health matter; discusses the ethical and policy issues stemming from their health needs and from illegal status; and concludes with a brief look at some implications of the Simpson-Mazzoli Immigration and Reform Act, currently before Congress. The paper suggests that the illegal status of undocumented workers intensifies their health risks; that the immigrants' responsibility for budget short-falls in public services is not as clearcut as frequently assumed; and that legislation aimed at regulating the status of immigrant workers in the U.S. is unlikely to solve many of the central problems.     

Courts and health policy: judicial policy making and publicly funded health care in Canada

The 1982 Canadian Charter of Rights and Freedoms provided political actors with the opportunity to make rights-based challenges to public policy decisions. Two challenges launched by providers and consumers of health care illuminate the impact of judicial review on health care policy and the institutional capacity of courts to formulate policy in this field. The significant impact of rights-based claims on cross-jurisdictional policy differences in a federal regime is noted.     

Making sense of the global health crisis: policy narratives, conflict, and global health governance

Health has become a policy issue of global concern. Worried that the unstructured, polycentric, and pluralist nature of global health governance is undermining the ability to serve emergent global public health interests, some commentators are calling for a more systematic institutional response to the "global health crisis." Yet global health is a complex and uncertain policy issue. This article uses narrative analysis to explore how actors deal with these complexities and how uncertainties affect global health governance. By comparing three narratives in terms of their basic assumptions, the way they define problems as well as the solutions they propose, the analysis shows how the unstructured pluralism of global health policy making creates a wide scope of policy conflict over the global health crisis. This wide scope of conflict enables effective policy-oriented learning about global health issues. The article also shows how exclusionary patterns of cooperation and competition are emerging in health policy making at the global level. These patterns threaten effective learning by risking both polarization of the policy debate and unanticipated consequences of health policy. Avoiding these pitfalls, the analysis suggests, means creating global health governance regimes that promote openness and responsiveness in deliberation about the global health crisis.     

National health policy: Efficiency-equity synchretism

A new emphasis in national health policy to encourage efficiency has been born in an environment of slower economic growth and an aging population. The increased reliance on market incentives to reduce health care costs does not signal the abandonment of equity as a social objective. To the contrary, the new emphasis on efficiency is intended to provide more and better health care through the generation of savings from the use of management systems to improve productivity. Market incentives and new management systems to increase efficiency are not the antithesis of equity but tools to provide better health care to the poor and to the elderly in an environment of fiscal constraints.     

The work the document does: research, policy, and equity in health

At the center of the politics of health equity, in many countries and circumstances, stands a signal report of research. This article is concerned with what might be described as the architecture of such documents, including how they are produced and organized and the relationships they demonstrate with others that parallel, precede, and succeed them. The article examines how scientific and political authority is established and comments on the evidence of cross-national learning that these documents reveal. It discusses differences in how the problem of health equity is constructed in different countries and how research findings are converted into policy recommendations. It begins to trace a process of implementation by noting how these documents are referred to and written about. The argument is that the politics of health equity are expressed or realized in the documents and reports, which are its principal vehicle. This is not to claim that there is no world beyond the text or that the world somehow is a text, but that to fully understand that world we must understand the text and the work it does.