Pegram v. Herdrich: On peritonitis, preemption, and the elusive goal of managed care accountability

Managed care presents the paradox of organizations having real power over people's lives without there being clear or consistent means of ensuring accountability. In Pegram v. Herdrich, the United States Supreme Court struggled with whether "fiduciary duties" under the federal Employee Retirement Income Security Act (ERISA) could be used to counterbalance the incentives that HMOs have to deny necessary care. Given press coverage of the case, however, it was easy to get the impression that the managed care industry itself was on trial in Pegram. This report examines the political and legal forces underlying the dispute and analyzes the Supreme Court's unanimous rejection of the notion of federally imposed duties for HMOs. In the absence of ERISA fiduciary obligations, attention must now shift to developments in state tort law, the scope of federal ERISA preemption, and the prospect of legislative reform. The report concludes with an exploration of how the elusive goal of managed care accountability might be pursued in the wake of Pegram.     

Race,politics, and punishment

This paper empirically evaluates two competing theories of electoral accountability in the context of New Orleans’ 2006 mayoral election. According to the democratic efficiency theory, voters can successfully punish ineffective political agents by removing them from office. In contrast, the public choice theory argues that the bundled nature of political goods prevents voters from successfully holding ineffective politicians accountable. We find that although there is limited support for the punishment effect predicted by the democratic efficiency theory, this effect is overwhelmed by the fact that the bundle of goods politicians offer contains elements that pull in opposing directions. This prevents the punishment effect from having any real impact, leading to democratic failure. Our results support the public choice theory of electoral (un)accountability.     

Balancing public health and practitioner accountability in cases of medical manslaughter: reconsidering the tests for criminal negligence-related offences in Australia after R v Patel

In 2010 Dr Jayant Patel was convicted of several offences on the basis of criminal negligence. Following the Queensland Court of Appeal's 2011 endorsement of the trial judge's decision, the case provides a timely opportunity to review prosecutions for medical negligence criminal offences throughout Australia and to critically examine the tests in assessing whether the balance has been correctly struck. The author argues that the thresholds required for prosecutions for criminal negligence for medical manslaughter are problematic and unduly onerous, and do not adequately strike the balance between the utilitarian value in health care and patient safety, on the one hand, and practitioner accountability and deterrence, on the other. This article considers reforms to remedy the imbalance, including a reformulation of the Criminal Code (Qld) and common law thresholds, proposals for the enactment of a separate offence of criminally negligent manslaughter and the utilisation of corporate prosecutions for manslaughter liability to broaden accountability in health care and promote patient safety on a systemic level.     

Obesity, courts, and the new politics of public health

Health care politics are changing. They increasingly focus not on avowedly public projects (such as building the health care infrastructure) but on regulating private behavior. Examples include tobacco, obesity, abortion, drug abuse, the right to die, and even a patient's relationship with his or her managed care organization. Regulating private behavior introduces a distinctive policy process; it alters the way we introduce (or frame) political issues and shifts many important decisions from the legislatures to the courts. In this article, we illustrate the politics of private regulation by following a dramatic case, obesity, through the political process. We describe how obesity evolved from a private matter to a political issue. We then assess how different political institutions have responded and conclude that courts will continue to take the leading role.     

Agency Accountability Strategies After Liberalization: Universal Service in the United Kingdom, France, and Sweden

Liberalization of key network industries is often said to reduce accountability by undermining its traditional mechanisms. Liberalization, others say, promotes accountability by creating new channels and mechanisms. This article suggests that neither view is sufficiently nuanced. Accountability comes in many forms, and the question is less "how much" accountability there is, but what form it takes. And accountability will take different forms in relation to different issues, even within the same organization. Examining accountability in relation to the provision of universal service in electricity and telecommunications, this article demonstrates that in the regimes studied, agencies were generally accountable for providing universal service by deferring, to the maximum possible extent, to political actors or stakeholders. However, when faced with an expert technical question—in this case, determining the costs of the universal service—agencies stressed their professional judgment and transparency. This observation supports a wider hypothesis concerning the conditions under which a variety of agency accountability strategies may be adopted.     

Access, accountability and authority: Corruption and the democratic process

Democratic systems face the challenge of sustainingtheir political authority while simultaneouslyproviding access to the political system for theircitizens, and ensuring existence of mechanisms for theformal and political accountability of those inoffice. The connections between these threecomponents, and between them and corruption, arecomplex. The paper suggests ways in whichaccountability may undermine authority through theblurring of distinctions between formal and politicalaccountability, by ham-stringing politicalinstitutions, by creating incentives for corruptpractices, and by politicising accusations ofcorruption. Access can be similarly destabilising andcorrupting, where trust is low and compliance withrules weak; and a basic problem with securing highlevels of trust is that the materials from which suchtrust is manufactured are often the very things whichaccountability mechanisms regard as corrupt – localnetworks, clientelism, and personal loyalties andfriendships. In democratising states, attackingthese elements can eradicate rather than enhance thebasis for well-regulated access.Different democratic systems have evolved differentways of balancing these three components. Theparticular institutional form the balance takes willhave a major impact on the types of corruption thesystem will face, and on the solutions which areappropriate. However, the tendency in internationalcircles is for one highly idiosyncratic understandingof this balance to hold sway, with potentiallydestabilising consequences when applied to theanalysis of corruption, especially in democratisingstates. The paper concludes that attempts to reduce corruptionand increase accountability by increasingparticipation and access are flawed. Access mayincrease the risk of corruption, while accountabilityremains a classic public good on which free-ridingwill be widespread. Corruption control in democracieswill not be solved by more democracy – indeed, itmight need less.     

行政问责制走向刍议

探索行政问责制的走向,对于行政问责制向纵深发展,促进我国的民主政治建设和建设服务型政府有着重要的意义。要使行政问责制进一步规范化,必须由权力问责走向制度问责,由以同体问责为主走向同体和异体共同问责,由事后问责、问题问责、火线问责走向全过程问责、常态问责和终身问责,由外部问责走向内外部结合问责,由以政治问责为主走向政治与道义问责并重。     

Reform, change, and continuity in Finnish health care

This article describes some essential aspects of the Finnish political and governmental system and the evolution of the basic institutional elements of the health care system. We examine the developments that gave rise to a series of health care reforms and reform proposals in the late 1980s and early 1990s and relate them to changes in health care expenditure, structure, and performance. Finally, we discuss the relationship between policy changes, reforms, and health system changes and the strength of neo-institutional theory in explaining both continuity and change. Much of the change in Finnish health care can be explained by institutional path dependency. The tradition of strong but small local authorities and the lack of legitimate democratic regional authorities as well as the coexistence of a dominant Beveridge-style health system with a marginal Bismarckian element explain the specific path of Finnish health care reform. Public responsibility for health care has been decentralized to smaller local authorities (known as municipalities) more than in any other country. Even an exceptionally deep economic recession in the early 1990s did not lead to systems change; rather, the economic imperative was met by the traditional centralized policy pattern. Some of the developments of the 1990s are, however, difficult to explain by institutional theory. Thus, there is a need for testing alternative theories as well.     

Accountability and psychiatric disorders: How do forensic psychiatric professionals think?

Swedish penal law does not exculpate on the grounds of diminished accountability; persons judged to suffer from severe mental disorder are sentenced to forensic psychiatric care instead of prison. Re-introduction of accountability as a condition for legal responsibility has been advocated, not least by forensic psychiatric professionals. To investigate how professionals in forensic psychiatry would assess degree of accountability based on psychiatric diagnoses and case vignettes, 30 psychiatrists, 30 psychologists, 45 nurses, and 45 ward attendants from five forensic psychiatric clinics were interviewed. They were asked (i) to judge to which degree (on a dimensional scale from 1 to 5) each of 12 psychiatric diagnoses might affect accountability, (ii) to assess accountability from five case vignettes, and (iii) to list further factors they regarded as relevant for their assessment of accountability. All informants accepted to provide a dimensional assessment of accountability on this basis and consistently found most types of mental disorders to reduce accountability, especially psychotic disorders and dementia. Other factors thought to be relevant were substance abuse, social network, personality traits, social stress, and level of education.     

State services for children: an exploration of who benefits, who governs

In recent years, equity, choice, and efficiency issues in the provision of education have received much attention and analysis. Yet, in the area of other state services for children (health, protective services, day care, etc.), there has been scant concern for equity, efficiency, or choice, despite the fact that out-of-school influences can be crucial in determining in-school performance. This paper reports on work in progress that reaches the following initial conclusions: 1. In the field of children's social services, data compilation is approximately 20 years behind the state of the art for education. Basic data on services provided is not collected for submission to state or federal authorities in any standard format on a recurring basis. 2. From the limited data available, the access of children to quantity and quality in social service programs varies enormously within states. The variations are much larger than those discovered in the public financing of education even before the recent school finance reform movement (1968-1978). 3. Federal allocations to states for social service programs comprise a substantial proportion of state Title XX budgets. For several reasons, the degree of accountability for these funds is less than that for federal education grants. 4. In all three states Title XX state allocations to localities are purported to be based on need. Closer examination of the formulas, and interviews with policy makers, revealed that Title XX allocations are determined primarily by political criteria.     

试论政府善治视域下我国行政问责制的建构

在我国目前的政治语境下，建立和实施行政问责制具有重要的现实意义。行政问责制是建设责任政府、推进民主政治的一个重要途径，也是实现政府良好治理的关键。然而，目前我国行政问责制在实践中仍面临异体问责薄弱、问责法律缺失、政府信息公开匮乏等诸多困境。因此，将成为加强异体问责，实现问责主体的多元化；健全行政问责的法律体系；推行政务公开，实现“阳光行政”。     

Legislatures of Small States: A Comparative Study

This article, drawing upon a quantitative survey of over 80 parliamentarians, as well as website surveys combined with qualitative interviews, explores the degree of usage of Information and Communication Technologies (ICTs) by Swedish parliamentarians. It also begins to consider any implications for party organisations and parliamentary authorities. The authors suggest that, by 2005, Swedish MPs were becoming ‘electronic parliamentarians’ and that this, combined with the growing usage of political blogs, places increasing demands upon party organisations and the Riksdag to consider the broader management and accountability issues of greater ICT usage by individual MPs. The authors argue that there is a pressing requirement for further research on these organisational and institutional dimensions by scholars of legislative studies, particularly, given the developments in ICT-advanced political systems, like Sweden.     

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.     

Making the Health Insurance Flexibility and Accountability (HIFA) waiver work through collaborative governance

This paper argues that collaborative governance should be an essential component in any HIFA waiver proposal, due to the fact that the health care system is moving away from a federal and hierarchical program design and implementation towards a more local, collaborative approach. As several current collaborative projects demonstrate, collaboration may overcome barriers to health expansion program success, such as stakeholder buy-in, notice, and state access to private health coverage information. Furthermore, collaboration within the context of the HIFA waiver process may maximize the strengths of current collaborations, such as providing: (a) access to greater and more stable funding sources; (b) access to a facilitator that can collect and distribute data; and (c) an avenue for accountability. Multiple challenges in ensuring collaborative governance are reviewed. Ms. Zabawa argues that these challenges are not insurmountable if states adopt a truly collaborative approach to designing and implementing programs under the HIFA waiver; there may be hope in expanding and improving health coverage, since collaboration is the most appropriate mechanism to address the complexity of health system reform.     

Fiscal transparency puzzle and electoral institutions: applying a 3Ds approach for tracking the action cycle in Egypt

This article aims at contributing to the discussion on the fiscal transparency puzzle. The authors challenge the idea that fiscal disclosure can directly increase fiscal accountability. Using an original data set at the level of individual members of parliament (MPs) in the Egyptian parliament, constructed from content analysis of budgetary discussions during the period 2000–10, it is shown that political incentives determined by a majoritarian electoral system curbed the willingness to check government fiscal behaviour, even among opposition MPs. This is because MPs still favoured pork-barrel behaviour to boost their re-election chances. Moreover, fiscal data disclosed could not be communicated to voters and the opposition showed a relatively higher avoidance against fiscal disclosure. The authors conclude that the electoral system is a dominant factor in shaping the final effect of transparency given its influence on the structure of political incentives.     

Confrontation, consent, and corporatism: state strategies and the medical profession in France, Great Britain, and West Germany

The economic disorders of the last decade have compelled European welfare states to seek more stringent controls over costly social policies such as health care, thus circumscribing professional sovereignty. However, several factors--institutional structure, cultural values, political/economic circumstances, patterns of state/professional relations--constrain the policy alternatives available to governments, and make fundamental reform very difficult to achieve. After analyzing these factors and the reform policies adopted in France, Great Britain, and West Germany, this article will examine and compare the strategies pursued to meet professional resistance to change.     

Technology assessment and the sociopolitics of health technologies

In a growing number of countries, health technology assessment (HTA) has come to be seen as a vital component in policy making. Even though the assessment of the social, political, and ethical aspects of health technology is listed as one of its main objectives, in practice, the integration of such dimensions into HTA remains limited. Recent social scientific research on the inherently political nature of technology strongly supports such a comprehensive approach. The growing claims by and on behalf of consumer groups also suggest that HTA should be informed by a broader set of perspectives. Using the example of the cochlear implant in children, this essay compares the professed objectives of HTA with typical practice and explores possible explanations for the discrepancies observed. A second example, home telemonitoring for elderly persons, demonstrates how the types of evidence considered by HTA and the process through which assessments are produced may be reconsidered. We argue for the formal integration of the sociopolitical dimensions of health care technologies into assessments. The ability of HTA to more fully address important issues from a public policy point of view will increase by making explicit the sociopolitical nature of health care technologies.     

THE LAWS,POLICIES, AND POLITICS OF REGULATING LEAD POLLUTION IN CHINA

This article examines the politics, laws and policies related to regulating lead pollution from lead-acid battery related manufacturing facilities in China. Particularly, this paper examines how China＇s Ministry of Environmental Protection （MEP） was able to force the temporary closure of nearly 90 percent of lead-battery manufacturing facilities within a period of months in 2011, after years of enforcement failures. The authors analyze the extent to which the Government＇s response to address lead pollution was based on laws and policies that can be systematically and consistently deployed by MEP as needed, or whether such measures are reliant on political will from outside MEP. Additionally, the authors are concerned with the extent to which China ＇s governance response to lead pollution primarily addresses environmental and public health issues; or rather it primarily addresses political and economic development issues, and whether this difference is significant. The article makes suggestions for how China can improve its environmental enforcement, and in so doing, contributes to a growing field of scholarship that examines environmental governance issues in the context of developing countries.     

The dynamics of health care opinion, 2008-2010: partisanship, self-interest, and racial resentment

Recent debate over the Patient Protection and Affordable Care Act highlights the extent of party polarization in Washington. While the partisan divide on this issue is stark among political elites, it is less clear how the mass electorate has responded to this divisive conflict. In this article we examine individual-level dynamics in health care attitudes between 2008 and 2010. We find partisan attachments and self-interests strongly predict change in health care attitudes, with Republicans growing more opposed to universal health insurance between 2008 and 2010, and those personally worried about medical expenses less likely to abandon support. We find, however, that the effect of partisanship is moderated by self-interest, with strong Republicans significantly less likely to switch to opposition if they were personally worried about medical expenses. Finally, we find that health care policy preferences, already tinged with racial attitudes in 2008, became increasingly so by 2010.     

The Loosening of Professional Boundaries and Restructuring: The Implications for Nursing and Medicine in Ontario, Canada

This paper suggests that the combination of health care restructuring, legislation expanding, and redefining a regulated health profession in Ontario, Canada, has reduced medical dominance and increased managerial dominance of health care professionals. The paper focuses on nurses and doctors, and examines the effects of the Regulated Health Professions Act and the changes occurring within the health care system on their political, clinical, and economic autonomy. It argues that there has been a redistribution of power in the health care sector and suggests that the present autonomy of health care professionals is limited, and may be limited even further as the technical side of health care is prioritized over the indeterminate side.