State Medicaid reform under Section 1115 demonstration authority

Given the complexity of federal Medicaid law and the limitations it imposes on state flexibility, it is likely that states will continue to ask the Secretary to grant waivers under Section 1115 to allow them to pursue new approaches to health care reform. The results of currently operational Section 1115 projects involving statewide managed care systems will be useful in evaluating the Medicaid reform measures currently under discussion in other states and at the federal level. In particular, the ability of the states to control Medicaid and indigent care costs and to utilize federal dollars more efficiently should prove important in evaluating a block grant approach to federal Medicaid funding. Moreover, Section 1115 project results that bear on the sufficiency of various Medicaid capitation rate methodologies will also be of value as more states expand the use of managed care arrangements for their Medicaid populations.     

The Department of Health and Human Services issues proposed regulations on physician incentive payments by hospitals

Hospitals tempted to operate their own physician incentive plans are reminded that, under OBRA 1986, they are precluded from paying physician incentives of any kind to reduce or limit Medicare or Medicaid covered services. In light of the proposed regulations and the guidance of the preamble, hospitals should review their incentive plans to determine whether physicians providing direct patient care are receiving prohibited payments. Further, supervising physicians who are receiving incentives for certain hospital departments may not influence direct care over patients served by those departments, even through other physicians. Some risk may also exist if incentives are based on a formula that considers patients of the supervising physician's medical group. Finally, it may be useful to develop a utilization and quality of care review program specifically designed to assure that patient undertreatment does not occur as a result of any supervising physician incentive program.     

Federal policy mandating safer cigarettes: a hypothetical simulation of the anticipated population health gains or losses.

If manufacturing a safer cigarette is technically possible--an open question--then mandating that tobacco manufacturers improve the safety of cigarettes would likely have both positive and negative implications for the nation's health. On the one hand, removing toxins may reduce the incidence of smoking-related diseases and premature mortality in smokers. On the other hand, smokers might be less inclined to quit, those who have quit might resume the habit, and youth who have never smoked will have one less reason to avoid tobacco use. To assess the expected population health impacts of a legislative or regulatory mandate, we created the Tobacco Policy Model, a system dynamics computer simulation model. The model relies on secondary data and simulates the U.S. population over time spans as long as 50 years. Our simulation results reveal that even if requiring cigarettes to be safer makes smoking more attractive and increases tobacco use, a net gain in population health is still possible.     

Leviathan and Fiscal Illusion in Local Government Overlapping Jurisdictions

This paper integrates twomodels of local government behavior,leviathan and fiscal illusion, into theframework of overlapping jurisdictions.Estimation of the leviathan and fiscalillusion variables without accounting forvertical effects between overlappingjurisdictions results in overestimation ofthe horizontal effects. Using a medianvoter model and municipal and county datawe find support for the leviathan modelusing traditional tests. These effects arelargely offset, however, when the test isset within the context of the verticalrelationship. We find that municipal percapita expenditures and county per capitaexpenditures are symmetricallycomplementary.     

The artist as a medium and the artwork as metaphor in Murakami Haruki’s fiction

Abstract

In many of Murakami Haruki’s works, the protagonist is in a profession close to the world of literature, although usually not exactly a writer. In their role as translators, advertising copywriters, journalists, or editors, Murakami’s protagonists are invested with the task of rearranging fragments of reality into narrative or artistic form, and/or of transmitting a message. This process is emotionally charged, often involving a supernatural dimension. While the process of reconstructing a narrative is largely unconscious, the narrator’s choice to act in this capacity is deliberate, and is presented as a way of fulfilling his responsibility towards others. I read this element as an expression of Murakami’s vision of the role of a writer in society. The figure of the artist-narrator takes an interesting form in Kishidanchō-Goroshi (Killing Commendatore, 2017), where the protagonist, a visual artist specialising in realistic portraits, decides to pursue a more creative approach to painting that leads him to a series of supernatural adventures. Through a close reading of the novel, this article investigates how Murakami’s portrayal of the artist as a shaman-like figure functions like a metaphor for the role of the literary author as a catalyst that enables people to connect with their inner self and with each other.