The interplay between economic and political logics: path dependency in health care in England

The purpose of this article is to use the ideas of path dependency to understand why policies implemented by governments for health care in England were and are suboptimal in terms of the control of total costs, the equitable distribution of hospital services, and efficiency in delivery. We do this by relating the economic logic of achieving these objectives to the political logic of a state-hierarchical system in which ministers are accountable for the effects of policies and doctors largely decide the supply and demand of health care. The initial policy path of the National Health Service (NHS) controlled costs but lacked systems to achieve equity and efficiency in the funding of hospitals. Policies were introduced to achieve equity, but not efficiency, in the 1970s. The Thatcher government sought efficiency through a budgetary squeeze in the 1980s, which culminated in the NHS funding crisis of 1987 - 1988. The result was the policies of the NHS internal market, which promised efficiency by introducing a purchaser-provider split and a system of provider competition in which money would follow the patient. These promises justified an injection of extra funds for three years, but only a pallid model of the internal market was implemented. The Blair government abandoned the rhetoric of competition but maintained the purchaser-provider split and continued to constrain total NHS costs, which resulted in the funding crisis of 1998 - 1999. Current policies are to substantially increase spending on health care and reintroduce a system of provider competition in which money will follow the patient.     

Polydrug fatality involving metaxalone

A 29-year old female with a history of depression was found dead in a hotel room. The death scene investigation found empty pill bottles and an empty liter bottle of wine. Metaxalone, a centrally acting muscle relaxant, along with citalopram, ethanol, and chlorpheniramine were identified in the postmortem samples and quantitated by gas chromatography-mass spectrometry. The concentration of metaxalone in femoral vein blood was 39 mg/L. The heart blood concentration was 54 mg/L. Femoral vein blood concentrations of citalopram and chlorpheniramine were 0.77 mg/L and 0.04 mg/L, respectively. Ethanol levels were 0.13 g/dL in vitreous and 0.08 g/dL in heart blood. Other tissue samples were also analyzed. The authors consider the metaxalone concentrations toxic and potentially fatal. The citalopram concentrations were lower than those reported in fatal cases for this drug alone. Death was ascribed to polydrug abuse/overdose with metaxalone a major contributor. This represents the first reported case to our knowledge in which a metaxalone overdose significantly contributed to death.     

How Large Should the Strike Zone Be in “Three Strikes and You're Out” Sentencing Laws?

So-called three strikes and you're out sentencing laws for criminal offenders have proliferated in the United States. The laws vary considerably in their definitions of what constitutes a strike. This paper adapts the classic Poisson process model of criminal offending to investigate how varying sentence lengths and definitions of what constitutes a strike affect the effectiveness and cost-effectiveness of these sentencing laws. In particular, it asks whether, by using different definitions for the first, second, and third strikes or different sentence lengths, one can make the resulting incarceration more efficient in the sense of incapacitating more crimes per cell-year served.