The quest for a better performing health system: Public expertise and corporate management recipes in France

Though the government pledged to cut the public deficit from 7.7% of the gross domestic product in 2010 to 3% by 2013, thereby responding to EU Normative power, health expenditures continue to rise, because public demands are higher and more social problems are handled in the health care setting. With French budget deficit threatening France's credit rating, novel instruments were needed. These included corporate management recipes (e.g., pay for performance contracts, patient volume targets, and management by objectives), new compensation mechanisms (e.g., activity‐based accounting and a nationwide scale of health care costs) and far‐reaching laws (e.g., the 2009 HPST bill). Our approach investigates some critical elements of the French health care system. We focus on primary (e.g., family physicians and General Practitioners) and secondary (e.g., hospital and specialty) care. We explore how policies such as the standardization of health services, the regrouping of health policy decisions within the larger Regional Health Agencies, affected citizens' engagement and physicians' autonomy. A French welfare elite pursued a hybrid strategy, regulating quasi‐markets of care providers in a postcompetitive government, while creating supportive conditions for a vibrant private hospital sector. Reforms also emphasized evidenced‐based policy, outputs‐rather than outcome‐measurement, and performance evaluation in a bid to streamline the delivery of health services.     

Recentralization and vertical alignment in the French health‐care system

In foreign exemplars, key new public management (NPM) features such as decentralization and devolution of health‐care responsibilities had outcomes below expectations. Other NPM traits such as the patient as overseer of reforms or the empowerment of patient remained elusive. In France, the integration of public values such as greater participation of patients and local actors (NGOs and elected officials) and NPM‐driven private values such as performance evaluation has yet to be seen. Taking advantage of NPM's failings and austerity agenda, a French welfare elite regained control over health‐care policy decisions at the expense of regions and other local actors. NPM outcomes were below expectations. Austerity cures led to weakening of the regional decision spaces, which can be explained under the principal–agent relationship. Accountability shifted to managerial (the professionalization of hospital managers) and legal (governance via regulations) forms in a bid to restore central government control. A democratic recess results from the lack of public engagement in recent health reforms.     

The EU Fundamental Rights Policy as a Source of Euroscepticism

This article analyzes how the development of the European Union (EU) fundamental rights policy feeds Euroscepticism—and notably political Euroscepticism—within segments of national political elites in EU Member States. More specifically, it argues that this relatively new policy also gives rise to a new form of political Euroscepticism, which has been defined as “value-based Euroscepticism,” e.g., the perception that the EU via its fundamental rights policy, unduly interferes in matters where value systems and core domestic preferences on ethical issues are at stake. This happens in a context where the EU is resented, by some segments of political elites, for allegedly empowering diverse groups (such as ethnic minorities, immigrants' associations, judges, and so on) at the expense of popular sovereignty. This resentment is exacerbated by the fact that national governments are increasingly submitted to the critical assessment of EU-level actors (e.g., the European Parliament or the European Commission) in terms of democratic credentials.     

A Case of Strange Bedfellows in the EU: An Institutional Perspective on the French–Swedish Cooperation on Alcohol Control

Some relationships in modern politics may intuitively be more difficult to understand than others. This article deals with what might be referred to as a case of strange bedfellows, i.e. the French–Swedish cooperation on alcohol control in the European Union (EU). The French government has actively supported the Swedish government on several occasions in discussions and disputes over alcohol control policy issues at the EU level, and this article presents and discusses three different interpretations of this support. It is concluded that, rather than reflecting current economic calculations or matching policies, the French support should be viewed in relation to an institutional perspective emphasising the importance of historical paths and inefficient histories.     

Gated communities in America: Walling out the world?

Abstract

Gated communities—enclaves of homes surrounded by walls, often with security guards—are becoming increasingly popular in America. This article introduces and analyzes findings of a Fannie Mae Foundation—sponsored panel on gated communities held at the 1997 Association of Collegiate Schools of Planning annual conference. A key finding is that many people choose to reside in gated communities because they believe that such places reduce risk, ranging from the mundane (e.g., unwanted social exchanges) to the high stakes (e.g., declining home values).

In many ways, gated communities deliver what they promise, by providing an effective defense against daily intrusions. However, some of their benefits entail a high social cost. A sense of community within gated communities comes at the expense of a larger identity with the region outside. Gated communities manifest and reinforce an inward‐focused community culture, where the tension between the individual and society tilt toward self‐interest.     

The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions

The U.S. population receives suboptimal levels of preventive care and has a high prevalence of risky health behaviors. One goal of the Affordable Care Act (ACA) was to increase preventive care and improve health behaviors by expanding access to health insurance. This paper estimates how the ACA‐facilitated state‐level expansions of Medicaid in 2014 affected these outcomes. Using data from the Behavioral Risk Factor Surveillance System, and a difference‐in‐differences model that compares states that did and did not expand Medicaid, we examine the impact of the expansions on preventive care (e.g., dental visits, immunizations, mammograms, cancer screenings), risky health behaviors (e.g., smoking, heavy drinking, lack of exercise, obesity), and self‐assessed health. We find that the expansions increased insurance coverage and access to care among the targeted population of low‐income childless adults. The expansions also increased use of certain forms of preventive care, but there is no evidence that they increased ex ante moral hazard (i.e., there is no evidence that risky health behaviors increased in response to health insurance coverage). The Medicaid expansions also modestly improved self‐assessed health.     

Changing the conventional rules: Surveying homeless people in nonconventional locations

Abstract

This paper describes the feasibility, validity, and cost‐effectiveness of supplementing surveys of shelter clients with surveys of people from nondwelling places (e.g., public places such as bus stations, parked cars and trucks, and abandoned buildings), nonresidential service locations (e.g., soup kitchens, day programs, health clinics), and other residential settings (e.g., jails, hospitals, group homes). The purpose of these supplements is to develop a more accurate estimate of how many homeless people there are, what their needs are, and the extent to which their needs are being met. The essential feature of these attempts involves systematic searches on a sample basis for homeless persons in these places. Reviewing ten studies that have attempted such surveys in the past decade and four that are now attempting to do so, this paper examines the comparative advantages and disadvantages of each approach and when each would be most appropriate. Particular attention is paid to the feasibility and desirability of surveying nondwelling or street locations.     

New public management and the reform of French public hospitals

New public management (NPM) is not only an Anglo‐Saxon debate but also a French one, with some of its elements constituting structural components of the French state apparatus. How did it make its way into French hospitals? What core mechanism was at the center of NPM implementation in hospitals? We discuss the redisorganization of the health system under NPM, as it attempted to reassert the central government's power over regions and how it alienated the medical profession. The paper highlights inherent contradictions and other false promises within NPM. It was unable to contained cost, could no enhance accountability or increase civil participation. We then investigate post‐NPM reforms in French healthcare. Copyright © 2013 John Wiley & Sons, Ltd.     

The allure of technology: How France and California promoted electric and hybrid vehicles to reduce urban air pollution

All advanced industrialized societies face the problem of air pollution produced by motor vehicles. In spite of striking improvements in internal combustion engine technology, air pollution in most urban areas is still measured at levels determined to be harmful to human health. Throughout the 1990s and beyond, California and France both chose to improve air quality by means of technological innovation, adopting legislation that promoted clean vehicles, prominently among them, electric vehicles (EVs). In California, policymakers chose a technology-forcing approach, setting ambitious goals (e.g., zero emission vehicles), establishing strict deadlines and issuing penalties for non-compliance. The policy process in California called for substantial participation from the public, the media, the academic community and the interest groups affected by the regulation. The automobile and oil industries bitterly contested the regulation, in public and in the courts. In contrast, in France the policy process was non-adversarial, with minimal public participation and negligible debate in academic circles. We argue that California's stringent regulation spurred the development of innovative hybrid and fuel cell vehicles more effectively than the French approach. However, in spite of the differences, both California and France have been unable to put a substantial number of EVs on the road. Our comparison offers some broad lessons about how policy developments within a culture influence both the development of technology and the impact of humans on the environment.     

France and the International Financial Crisis: The Legacy of State‐Led Finance

Despite the far‐reaching liberalization of the French banking system over the past quarter century, French banks suffered far less in the international financial crisis (2007–2009) than banks in the United Kingdom and Germany. However, the French system also suffered far more—at least in the first stages of the crisis—than the banking systems of Southern Europe. By several measures, French banks were world leaders in financial innovation, and the French banking system was highly exposed to international market movements. The limited impact of the crisis, however, owed to the specificities of French “market‐based banking.” Deliberate state action over the two decades prior to the crisis created a specific kind of banking system and encouraged forms of financial innovation, the unintentional consequence of which was the limited exposure to the securitization that caused the damage wrought during the financial crisis.     

General courts,specialized courts,and the complementarity effect

Among the major decisions any legal system must make is deciding whether to establish general courts with broad jurisdiction, or specialized courts with limited jurisdiction. Under one influential argument—advanced by both judges and legal theorists—general courts foster coherence within the legal system. This Article identifies a distinct effect of establishing general courts: the “complementarity effect.” In the case of complementarity, general courts strategically apply different principles in different fields, such that litigants losing in one sphere (e.g., public law) are compensated in another (e.g., private law). We support this conjecture by analyzing three case studies.     

The Effect of the Charter of Rights on Canadian Federalism

Canadian experience under the 1982 Charter of Rights contradictsthe orthodox understanding of judicial review as a decentralizinginstitution that performs a checking or blocking function. Charterpolitics in Canada suggest that in a federal system, judicialreview can also enhance values and policies favored by the nationalgovernment at the expense of the constituent units. Rather thanweakening the policy capabilities of the federal government,the Canadian Charter has enhanced its influence. The Charterhas undermined the policy autonomy of the provinces by givinga policy veto to the Supreme Court, an institution that is morereceptive to the policy preferences of national elites, especiallyin the area of language policy. This has aggravated French-Englishrelations, because of the high incidence of judicial nullificationsof Quebec's restrictive language policies. Elite attempts tocompensate Quebec by way of new constitutional amendments (e.g.,the Meech Lake Accord) have been thwarted by the emergence ofan influential coalition of postmaterialist social interests,which use Charter litigation to promote their nonterritorialpolicy objectives. These "Charter Canadians"have opposed constitutionalamendments that would "weaken" the Charter or the Court. Thiscoalition has broken Canadian governments' historical monopolyon the constitutional amending process. By stimulating the democratizationof constitutional politics, the Charter has weakened the institutionsof consociational democracy and elite accommodation. This hasdiminished the influence of all the provinces, but especiallyQuebec, thereby contributing to the recent rise in secessionisttendencies within Quebec.     

Empirical Research and the Development and Assessment of Transitional Justice Mechanisms

In this paper, we demonstrate different methods of empiricalresearch available to transitional justice practitioners andscholars. Guidelines on how to conduct research in the fieldof transitional justice are outlined on the basis of the principlesof monitoring and evaluation for decision making, program developmentand policy development. We argue that such methods offer policymakers a systematic way to consult a population and constructa comprehensive view of what this population has experienced(e.g., violations), what they know (e.g., knowledge of varioustransitional justice mechanisms), what they believe in (e.g.,definition of justice) or what they need (e.g., accountability).Such knowledge is essential for developing effective evidence-basedtransitional justice programs.     

Multi-candidate equilibria

We demonstrate the existence of an electoral equilibrium in a model with three or more candidates. We use the same kinds of assumptions that have previously been used to establish existence in two-candidate models and have not had to make special assumptions regarding dimensionality (e.g., that there is only one dimension) or distribution of voter preferences (e.g., symmetry).     

Socialist Intergovernmental Policy During the Mitterrand Era

Many observers of French politics see intergovernmental decentralizationas President Mitterrand's most impressive domestic policy accomplishment.This article assesses the current state of affairs in the Frenchintergovernmental system by focusing on how Socialist reformshave altered relations among levels since the early 1980s. Itexamines the Mitterrand government's most recent effort to addressremaining nettlesome issues in a system that is, ten years afterthe first legislation, still very much influx. Using evolutionin intergovernmental finances as an indicator of changing center/peripheryrelations, this study reveals both fundamental transformationsand significant continuity in the French system.     

Placing Racial Stereotypes in Context: Social Desirability and the Politics of Racial Hostility

Past research indicates that diversity at the level of larger geographic units (e.g., counties) is linked to white racial hostility. However, research has not addressed whether diverse local contexts may strengthen or weaken the relationship between racial stereotypes and policy attitudes. In a statewide opinion survey, we find that black‐white racial diversity at the zip‐code level strengthens the connection between racial stereotypes and race‐related policy attitudes among whites. Moreover, this effect is most pronounced among low self‐monitors, individuals who are relatively immune to the effects of egalitarian social norms likely to develop within a racially diverse local area. We find that this racializing effect is most evident for stereotypes (e.g., African Americans are “violent”) that are “relevant” to a given policy (e.g., capital punishment). Our findings lend nuance to research on the political effects of racial attitudes and confirm the racializing political effects of diverse residential settings on white Americans.     

Taking the Law to Court: Citizen Suits and the Legislative Process

The institution of citizen suits is a decentralized form of public participation that allows citizens to influence the implementation of public laws in courts. How does this institution influence policymaking? This article proposes a model of citizen suits. It then analyzes how this institution influences legislative decisions. The legislature bargains to choose the budget, distributive spending, and spending on an ideologically contested public good (e.g., health care or environmental protection). I find that citizen suits enable courts to forge a compromise between opponents and proponents of the public good by responding to the diverse claims of citizens. Anticipating the mobilization of citizens in courts, legislators in turn craft more socially efficient bills, with less distributive spending, which better represent the distribution of preferences for the public good compared to when citizens have no role in the implementation of legislation.     

Can Leviathan governments mitigate the tragedy of the commons?

This paper explores the conjecture whether the Leviathan motive of politicians — to tax for the purpose of raising revenues rather than for benevolent, Pigovian motives — helps to overcome the inefficiency of international pollution spillovers such as in the cases of acid rain and global warming. It turns out that this conjecture is true in a static context that captures flow externalities, e.g., acid rain, as long as environmental damages are not too high. In contrast, Leviathan motives aggravate the already existing inefficiency in the case of stock externalities (e.g., global warming) despite probably high taxes at the beginning.     

Relationships between government size and economic growth: Japan's government reforms and evidence from OECD

This paper examines the relationship between government size and economic growth of 21 industrialized countries. Government size is measured by government final consumption expenditures and transfer payments. The relationship between government consumption is expected to increase GDP growth for developing countries, and reduce it for industrialized countries. Government consumption can contribute to increased economic growth. However, government consumption is likely to expand beyond an efficient level in industrialized countries. In contrast, transfer payments, and social welfare programs are likely to reduce economic growth for most countries. These programs reduce work incentives and encourage tax avoidance activities. Work disincentives and tax avoidance reduce economic growth. These expected relationships are consistent with economic performance and government size for the countries considered here. Inefficiency and excessive government growth are checked by voter feedback as tax burdens exceed the associated benefits. Unfortunately, government program costs and benefits are asymmetrically distributed. The resulting tendency is to expand government programs, particularly programs that benefit a majority of voters at the expense of a minority. This tendency becomes even more acute as the tax system becomes more progressive (i.e., tax burdens become concentrated. Reductions in government size are more likely with stagnant or declining economic growth, and in government programs whose costs are widely shared, compared to programs with widely shared benefits and narrowly shared costs.     

Nonverbal displays and political leadership in France and the United States

Because contemporary theories of politics discuss the appeal of leaders primarily in verbal terms, it is often difficult to go beyond anecdotes when explaining the effects of televized appearances of leaders and candidates. Experimental studies of the way American viewers respond to televized excerpts of leaders were replicated in France shortly before the legislative elections of March 1986, using comparable expressive displays of Laurent Fabius (then Social Prime Minister), Jacques Chirac (Gaullist Mayor of Paris who became Prime Minister), and Jean Marie LePen (head of the Front Nationale). Although the results show striking similarities in the system of nonverbal behavior in France and the United States, there are cultural differences in the role of anger/threat (which elicits more positive responses from French viewers than Americans) as well as variations in the evocative character of the facial displays of individual leaders. These experimental findings clarify recent discussions concerning the evolution of the French party system, providing insights into the role of political culture as well as leadership style in the media age.