Tension, compression, and shear: directions, stresses, and outcomes of health care cost control

"Control" of health care costs is often portrayed as a struggle between external, "natural" forces pushing costs up and individuals, groups, and societies trying to resist the inevitable. This picture is false. Control includes strenuous efforts by some to raise costs, and by others to resist those increases, and/or to transfer costs to someone else. But all such forces originate in the purposes and interests of individuals and groups. Health care cost control is a struggle among conflicting interests over the priorities of a society, and claims of "inevitability" are simply part of the political rhetoric of that struggle. International experience supports certain conclusions. First, there is no basis for the claim that limits on expenditure growth must threaten the health of (some members of) a society. Second, there is a substantial variety of experience with cost control. Failure in the United States is often presented as evidence of the impossibility of control, but most other countries have succeeded. Finally, control requires the direct confrontation of interests, with substantial build-up of stress. Advocates of expansion are more successful if they can transform compressive forces into efforts to shift the burden onto someone else. Pressures from providers in every country for "privatization" and/or payment by users reflect this recognition of economic interest.     

Book reviews

Roland Axtmann, Liberal democracy into the twenty‐first century: Globalization, integration and the nation‐state (Manchester University Press, Manchester, 1996), 198 pp., ISBN 0–7190–4304–2 (hb), 0–7190–4305–0 (pb)

Paul Kapteyn, The Stateless Market: The European Dilemma of Civilization (Routledge, London and New York, 1996), 194 pp., ISBN 0–415–12232–5 (hb), 0–415–12233–3 (pb)

Richard Werbner and Terence Ranger (eds), Postcolonial Identities in Africa (Zed Books, London & New Jersey, 1996), 292 pp., ISBN 1–85649–415–2 (hb), 1–85649–416–0 (pb)

Mark Wheeler, Politics and the Mass Media (Blackwell, Oxford, 1997), 274 pp., ISBN 0–631–19783–4 (hb), 0–631–19784–2 (pb)

Nigel Harris, The New Untouchables: Immigration and the New World Worker (Penguin Books, London, 1995), 254 pp., ISBN 0–14–014689‐X (pb)

Gilles Kepel, Allah in the West (Polity Press, Cambridge, 1997), 273 pp., ISBN 0–7456–1557–0 (hb), 0–7456–1558–9 (pb)

Leonard Weinberg, The Transformation of Italian Communism (Transaction Publishers, New Brunswick, New Jersey, 1995), 147 pp., ISBN 1–56000–180–1 (hb)

Brian Jenkins and Spyros A. Sofos (eds), Nation and Identity in Contemporary Europe (Routledge, London, 1996), x + 294pp., ISBN 0–415–12312–7 (hb), 0–415–12313–5 (pb)

Stuart Parkes, Understanding Contemporary Germany (Routledge, London, 1997), 247 pp., ISBN 0–415–14123–0 (hb), 0–415–14124–9 (pb)     

Explaining “Pain and Suffering” Awards: The Role of Injury Characteristics and Fault Attributions

The present research explored factors thought to affect compensatory awards for non-economic ham (pain and suffering) in personal injury cases. Experiment 1 showed that the nature and severity of the plaintiffs injury had a strong effect on perceptions of the extent of harm suffered and on award amounts. The parties' relatively active or passive roles in causing the injury affected assessments of their degree of fault, but perceived fault had little influence on awards. Experiment 2 replicated with more varied cases the strong impact of injury severity on harm perception and on awards for pain and suffering. In both studies, the disability and the mental suffering associated with injuries were stronger predictors of awards than were pain and disfigurement.     

Health care in Canada: patterns of funding and regulation

During the 1970s the share of health care expenditure in Canadian GNP remained roughly stable, in the range of 7-71/2 percent of GNP, in marked contrast to its escalation in most other countries (the U.S. in particular) and to previous Canadian experience. The shift to a stable pattern coincided with the completion of the Canadian system of universal comprehensive public hospital and medical care insurance. This paper explores how and why the public insurance system served to contain cost escalation. It then discusses the inadequacy of expenditure experience per se as a basis for health system evaluation--the same data will support claims of both "underfunding" and "spiralling costs." More serious questions involve the influence of alternative patterns of health care funding and delivery on the effectiveness and efficiency of care provision, and the resulting distributional patterns of care and income. A brief sketch is given of the present situation and future possibilities of Canadian health care under these heads.     

Does domestic politics limit the influence of external actors on ethnic politics?

Conclusion Domestic politics is naturally important in ethnic policies. However, in spite of their potency, domestic political factors are not always the most decisive. International organizations have influenced the Latvian and Estonian governments, and at times the Slovak and Romanian governments. However, the ability of different organizational strategies to overcome domestic opposition and thus bring about their desired policy varies widely. In most cases, actors need to use conditionality and aim it at the appropriate decision makers. In spite of their widespread use, efforts that rely solely on persuasion and diplomacy tend only to work when the domestic opposition is initially quite low or when ethnic minorities themselves have some bargaining power in the government. The key policy implication is that domestic factors do not make failure, or success for that matter, a foregone conclusion. For example, ethnic minority representation within the government coalition is not in itself a guarantee of passage of the policy preferences of the minorities. Conversely, the presence of authoritarian-style leadership does not automatically mean a rejection ethnic minority accommodation either, if organizations present their suggestions so that such leaders view it as being in their greater interests to maintain power. Conditionality that targets incentives to fit goals of the leadership can work. External actors are thus not justified in backing off from action based purely on a domestic analysis.     

Adolescent Depressed Mood in a Multiethnic Sample

This research assessed whether there is an impact of race-ethnicity on depressed mood among adolescents, independent of socioeconomic status, whether gender differences in depressed mood are apparent within all race-ethnicity subgroups, and whether pubertal development influences depressed mood in a similar manner within gender and race-ethnicity subgroups. A three-stage, area probability sampling frame was utilized to select adolescents, ages 12–17 years, for an in-person interview. Depressed mood was assessed by the Children's Depression Inventory. Compared to Whites, African Americans, or Asian Americans, Latinos reported more symptoms of depressed mood, a finding that was independent of socioeconomic status. Advancing puberty was associated with depressed mood only among females, but the timing of pubertal changes, relative to ones peers, was related to depressed mood among both males and females, and among Latinos.