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.     

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.     

Incentivizing professionals and patients: a consideration in the context of the United Kingdom and the United States

We are at the beginning of an era in which the pressure to secure the biggest possible "bang" for the health care "buck" is perhaps higher than it ever has been, on both sides of the Atlantic, and within the health policy discourse, incentives, for both professionals and patients, are occupying an increasingly prominent position. In this article, we consider issues related to motivating the professional and the patient to perform targeted actions, drawing on some of the evidence that has thus far been reported on experiences in the United Kingdom and the United States, and we present an admittedly somewhat speculative taxonomy of hypothesized effectiveness for some of the different methods by which each of these two broad types of incentives can be offered. We go on to summarize some of the problems of, and objections to, the use of incentives in health and health care, such as those relating to motivational crowding and gaming, but we conclude by positing that, following appropriate consideration, caution, and methodological and empirical investigation, health-related incentives, at least in some contexts, may contribute positively to the social good.     

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.     

Deconstructing Deliberation in the Appraisal of Medical Technologies: NICEly Does it?

Appraisals of medical technologies undertaken by the National Institute for Health and Clinical Excellence (NICE) have significant implications for the setting of priorities for health care expenditure in the NHS in England and Wales. NICE has been characterised as a deliberative body, an evaluation which reflects the recent attention paid by those working within the health policy community to the establishment of mechanisms which deliver procedural justice, in the absence of societal consensus upon the substantive values which should underpin distributive choices in health care. This article critically interrogates the assessment of NICE as deliberative in character. It also considers the relationship between legitimacy and deliberation in this policy context, in light of the claim that 'thickening proceduralisation' by establishing and enhancing deliberative structures and processes is a useful strategy for addressing regulatory problems.     

Policymaking cycles in mental health: critical examination of a conceptual model

Analysts have frequently used the concept of a cycle to describe the historical development of mental health policy in the United States. According to the "cyclical" perspective, the mental health system alternates between crests of high policy and program activity and troughs of stagnation and decline. Analysts also observe that past policy themes are periodically rediscovered, only to eventually lose favor and recede into the background once again. This article critically examines the cyclical model of mental health policymaking, placing it within a context of broader theoretical work on the dynamics of public policy formation. The purpose is to organize in a conceptually coherent way what has emerged as the leading theoretical approach to understanding the evolution of the mental health system; to identify major issues and ambiguities in the application of the cyclical framework to mental health policy analysis; and to derive some general insights about problems and possibilities in modeling policy change.     

“We Are the Visible Proof”: Legitimizing Abortion Regret Misinformation through Activists’ Experiential Knowledge

Since 2010, many abortion policies emerging at the state level have been designed around the idea of “abortion regret,” a scientifically discredited assertion that abortion causes long‐term health problems for women. Studies have examined the legal significance of regret claims in case law as well as the role scientific misinformation and uncertainty play in the policy process. However, scholars have given less attention to the intersection between abortion regret experiences and misinformation. We address this gap in the literature by examining how antiabortion activists' experiential knowledge continues to reinforce and legitimize misinformation contained in state policies. We explore the process of substantiating abortion regret misinformation by attaching it to activists' experiential expertise. Based on twenty‐three interviews with antiabortion activists, we argue that misinformation receives validation through the certainty of experiential knowledge, which activists mobilize around and use as a source of evidence in the policy process.     

酌定不起诉适用中面临的问题与对策——基于未成年人案件的实证研究

酌定不起诉具有贯彻宽严相济的刑事政策、程序分流、提高诉讼效率和合理配置司法资源等方面的功能。由于各种原因,酌定不起诉制度在实践中难以实现其承载的应有功能。基于对未成年人案件适用酌定不起诉的实际情况和适用中存在的突出问题,尽快修改酌定不起诉相关规定、改革考评机制、建立社会支持保障系统,才是解决酌定不起诉适用面临问题的关键。     

Tax administration as health policy: hospitals, the Internal Revenue Service, and the courts

Since 1969 federal tax policy has permitted nonprofit hospitals to turn away indigent patients or to transfer them to public hospitals. The Internal Revenue Service made health policy, but its officials remain convinced that they were not making policy at all. Convinced that it was reasoning from legal principles, the Revenue Service accepted the hospital industry's view of the history and purpose of hospitals. The federal courts further obscured the problem. Moreover, the Revenue Service took no interest in the effects of its ruling on the services provided by tax-exempt hospitals until 1989. We describe these events and seek to explain them by linking the recent history of health policy to the assumptions that govern the making of tax policy. We conclude that the making of health policy by tax officials who are not accountable for it and who believe that they are not making policy at all is not in the public interest.     

Urban Drug Problems, Policymakers and the General Public

The main focus of this paper is: how strong are people's opinions and policy preferences on the issue of drugs and drug users influenced by their own exposure to drug problems? From a general population survey conducted in eleven European cities, it is concluded that opinions and policy preferences are influenced only to a limited degree by exposure. The people who are not exposed to drug problems in their neighbourhood are more strongly inclined towards a repressive approach than the people who are affected by drug nuisance. Personal experiences with illicit drugs play an important part in the viewpoints. People who have tried drugs themselves lean far more strongly towards a health approach. That tendency is even stronger among those who are exposed to drug-related nuisance.     

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.     

Breaking gridlock: the determinants of health policy change in Congress

Prior to the 2010 health care reforms, scholars often commented that health policy making in Congress was mired in political gridlock, that reforms were far more likely to fail than to succeed, and that the path forward was unclear. In light of recent events, new narratives are being advanced. In formulating these assessments, scholars of health politics tend to analyze individual major reform proposals to determine why they succeeded or failed and what lessons could be drawn for the future. Taking a different approach, we examine all health policies proposed in the U.S. House of Representatives between 1973 and 2002. We analyze these bills' fates and the effectiveness of their sponsors in guiding these proposals through Congress. Setting these proposed policies against a baseline of policy advancements in other areas, we demonstrate that health policy making has indeed been far more gridlocked than policy making in most other areas. We then isolate some of the causes of this gridlock, as well as some of the conditions that have helped to bring about health policy change.     

American health policy: cracks in the foundation

Much American health policy over the past thirty-five years has focused on reducing the additional health care that is consumed when a person becomes insured, that is, reducing moral hazard. According to conventional theory, all of moral hazard represents a welfare loss to society because its cost exceeds its value. Empirical support for this theory has been provided by the RAND Health Insurance Experiment, which found that moral hazard--even moral hazard in the form of effective and appropriate hospital procedures--could be reduced substantially using cost-sharing policies with little or no measurable effect on health. This article critically analyzes these two cornerstones of American health policy. It holds that a large portion of moral hazard actually represents health care that ill consumers would not otherwise have access to without the income that is transferred to them through insurance. This portion of moral hazard is efficient and generates a welfare gain. Further, it holds that the RAND experiment's finding (that health care could be reduced substantially with little or no effect on health) may actually be caused by the large number of participants who voluntarily dropped out of the cost-sharing arms of the experiment. Indeed, almost all of the reduction in hospital use in the cost-sharing plans could be attributed to this voluntary attrition. If so, the RAND finding that cost sharing could reduce health care utilization, especially utilization in the form of effective and appropriate hospital procedures, with no appreciable effect on health is spurious. The article concludes by observing that the preoccupation with moral hazard is misplaced and has worked to obscure policies that would better reduce health care expenditures. It has also led us away from policies that would extend insurance coverage to the uninsured.     

Equity,access, and outcomes: The status of the art

A rationale for including analyses of outcome in evaluation of the impact and equity of changes in health care policy for the poor is presented. We first discuss problems in defining equity in and access to health care. Equity in access to health care requires equality of access only to those services that are believed to be efficacious. Three cost-containment strategies (restrictions in eligibility, coinsurance, and capitation) are then examined, and their limitations are discussed. Finally, directions for future research focusing on outcomes are suggested. Rather than using access to care to assess outcome, outcome is viewed as the framework for assessing access and equity.     

Market-oriented health care reforms and policy learning in the Netherlands

In this article we analyze the evolution of market-oriented health care reforms in the Netherlands. We argue that these reforms can be characterized as policy learning within and between competing policy programs. Policy learning denotes the process by which policy makers and stakeholders deliberately adjust the goals, rules, and techniques of a given policy in response to past experiences and new information. We discern three distinctive periods. During the first period (1988-1994), the prevailing corporatist and etatist policy programs were seriously challenged by the proponents of a new market-oriented program. But when it came to political decision making and implementation, the market-oriented program soon lost its impetus because it was technically too complex and could not provide short-term solutions to meet the urgent need for cost containment. During the second period (1994-2000), the etatist program regained its previously dominant position. In parallel to a strengthening of supply and price controls, however, the government also persevered in creating the technical and institutional preconditions for regulated competition. Moreover, public discontent over waiting lists and the call for more autonomy by individual providers and insurers strengthened the alliance in favor of regulated competition. This led to the revival of the market-oriented program in a 2001 reform plan. We conclude that the odds of these new post-2001 reforms succeeding are substantially higher than in the first period due to the technical and institutional adjustments that have taken place in the past decade.     

Nondecision making and inertia in Portuguese health policy

Despite there having been a positive context for initiating health care reforms in Portugal in the past fifteen years (accompanied by political consensus on the nature of the structural problems within the health care system), there has been a lack of reform initiatives. We use a process-based framework to show how institutional arrangements have influenced Portuguese health care reform. Evidence is presented to demonstrate inertia and nondecision making in three critical areas of Portuguese health policy: clarifying the public-private mix in coverage and provision, creating financial incentives and motivation for human resources, and introducing changes in the pharmaceutical market. Several factors seem to explain these processes, namely, problems in the balance of power within the political system, which have contributed to a lack of proper policy discussion; a lack of pluralism in the formation of health care policies (with low participation from citizens and high mobilization among structural interest groups); and the low priority of health care in public sector reforms. Portuguese politicians should be aware of the pitfalls of the current political system that constrain participatory arrangements and pluralism in policy making. In order to pursue health care reform, future governments will need to counterbalance the strong influence of structural interest groups.     

Incarcerated Mothers of Minor Children: Physical Health,Substance Use,and Mental Health Needs

Mothers of minor children serving sentences in a large Midwestern jail were screened for potential substance use problems and asked to report their physical and mental health status and treatment experiences. Of mothers screened for substance use problems, 72.1% had positive findings on the AUDIT-12, 56.7% reported at least one serious physical health problem, and 67.1% had received mental health treatment. More than two-thirds (68.8%) of the 240 mothers reported a co-occurring condition, and a third (33.8%) reported problems in all three spheres (substance use, mental health, and physical health). The relationship among the three health-related problems is examined as well as the characteristics of mothers related to having co-occurring health conditions. Given that the overwhelming majority of mothers reported more than one health-related problem, the changes to policy and practice need to avoid simplistic solutions.     

Risk,response, and mental health policy: learning from the experience of the United Kingdom

Policy makers in the United States and the United Kingdom recognize that mentally disordered offenders present special challenges to law enforcement, mental health, and social service systems, as well as the community. Although various policy initiatives have advanced over the past twenty years to improve the management of mentally disordered offenders, mental health policy has chronically failed in both countries. Because safety concerns have emerged as the mental health system has been "deinstitutionalized," debate is growing about whether the community-care approach works-for the community. This study argues that mental health policy fails because policy makers focus on the wrong risks and design policies that manage these risks in ways that increase the possibility of adverse clinical and economic outcomes. The argument made here uses the case of persons with severe mental illness in the United Kingdom as an example of the complex relationship between risk and policy making in democratic governance. Emphasis is on the nature of risk in mental health policy and how government responds to policy and political risks. Mental health policy in Britain is then analyzed in terms of its response to and management of risks. Mental health policy has historically mismanaged the risk issue in the United Kingdom and as such has set in motion the growing community-care backlash. The path to a better outcome lies in the responsible management of the right risks. Lessons from the United Kingdom experience can be usefully applied to mental health issues in many industrial democracies.     

THE CONSTITUTIONAL STATUS OF WOMEN: The Burger Court and the Sexual Revolution in American Law

This article analyzes the revolution in Constitutional Law concerning sex discrimination that has been brought about by the Burger Court. It provides an overview of both the doctrinal changes and the policy changes that have composed this legal revolution. It identifies certain policy areas that have troubled the Burger Court during this process and attempts to explain why some policy problems have proved more intractable than others. It concludes with a modest suggestion for dealing with those problems.