Why some market reforms lack legitimacy in health care

Market-oriented health policy reforms in the 1980s and 1990s generally included five kinds of proposals: increased cost sharing for patients through user fees, the separation of purchaser-provider functions, management reforms of hospitals, provider competition, and vouchers for purchasing health insurance. These policies are partly derived from agency theory and a model of managed competition in health insurance. The essay reviews the course of reform in five countries that had a national health service model in place in the late 1980s: Italy, New Zealand, Spain, Sweden, and the United Kingdom. Special consideration is given to New Zealand, where the market model was extensively adopted but short lived. In New Zealand, surveys and polls are compared to archival records of reformers' deliberations. Voters saw health care differently from elites, and voters particularly felt that health care was ill suited to commercialization. There are similarities across all five countries in what has been adopted and rejected. Some market reforms are more legitimate than others. Reforms based on resolving principal-agent problems, including purchaser-provider splits and managerial reforms, have been more successful, although cost sharing has not. Competition-based reforms in financing and to a lesser extent in provision have not gained legitimacy. Most voters in these countries see health care as different from other parts of the economy and view managerial reforms differently from policies that try to make health care more like other sectors.     

Revisiting renewable portfolio standard effectiveness: policy design and outcome specification matter

Renewable portfolio standards (RPS) differ widely across US states. Prior research findings on the effectiveness of these policies to stimulate renewable electricity deployment are equally wide ranging. This study investigates patterns of RPS policy design and analyzes the effects on policy outcomes measured at the level of utility compliance. Measuring organizational outcomes of RPS corrects for the first time the challenges of prior research focused on state-level renewable capacity or generation outcomes. The quantitative analysis also takes into account the complexity of RPS design, by making use of a state-by-state database of RPS design characteristics developed for this study. Patterns of RPS design across states are compared, including the compliance schedule, scope, eligibility of resources, quotas and subsidies, renewable energy credit provisions, as well as enforcement and penalties. Together, the map of state RPS design and the new approach to RPS outcome analysis illuminate the diversity of RPS policy practice across the United States. They suggest the need to both account for the variety of design characteristics and accurately specify the policy outcomes in evaluations of these policies.