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.     

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.     

Policy Transfer as a Form of Prospective Policy Evaluation: Challenges and Recommendations

This article focuses on policy transfer as a form of prospective policy analysis, which we define as policy makers' attempts to assess the effect of a policy or program before it is put in place. Despite a burgeoning literature on cross-national policy transfer, there has been little systematic comparison of cases to identify either common problems or potential strategies in the practice of policy transfer. This article sets forth a rational model of policy transfer and examines, in light of that model, case studies of cross-national policy transfer spanning different policy domains. Taking into account the constraints faced by policy makers, we relax standard rational decision-making criteria and make recommendations for improving the process of policy transfer as a form of prospective policy evaluation.     

The Structuring of Political Cleavages in Post-Communist Societies: the Case of the Czech Republic and Slovakia

Although sharing institutions for over seventy years, and transition pathways from communism, the two successor states of the former Czechoslovakia have faced distinct challenges in state-building and divergent economic fortunes. The aim of this paper is to investigate the extent to which these differing social economic problems have influenced the ideological bases of party politics and mass electoral behaviour in the two societies. Using data from national samples of the population of each country conducted in the spring of 1994, our analysis points to the existence of distinct issue cleavages dominating party competition in the two states: in the Czech Republic, partisanship relates mainly to issues of distribution and attitudes towards the West; in Slovakia, by contrast, these issues are only secondarily important in shaping voters' choice of party, while the main focus concerns the ethnic rights of Hungarians. The distinctive nature of the issue bases to politics in the two countries suggests one reason for the greater degree of political conflict evident in Slovak politics since the split and, more generally, provides evidence of the role of social conditions in shaping new political systems.