Journal of Health Politics, Policy and Law recent issues

Editor's Note

Sparer, M. S. — 2008-07-10

The Form and Context of Federalism: Meanings for Health Care Financing

France, G. — 2008-07-10

This article examines the meaning of federalism for health care financing (HCF) and is based on two considerations. First, federal institutions are embedded in their national context and interact with them. The design and performance of HCF policy will be influenced by contexts, the workings of the federal institutions, and the interactions of these institutions with different elements of the context. This article unravels these influences. Second, there is no unique model of federalism, and so we have to specify the particular form to which we refer. The examination of the influence of federalism and its context on HCF policy is facilitated by using a transnational comparative approach, and this article examines four mature federations: the United States, Australia, Canada, and Germany. The relatively poor performance of the U.S. HCF system seems associated with the fact that it operates in a context markedly less benign than those of the other national HCF systems. Heterogeneity of context appears also to have contributed to important differences between the United States and the other countries in the design of HCF policies. An analysis of how federalism works in practice suggests that, while U.S. federalism may be overall less favorable to the development of well-functioning HCF policies, the inferior performance of these policies is to be principally attributed to context.

Health Economists' Views of Health Policy

Morrisey, M. A., Cawley, J. — 2008-07-10

This article reports the views of a national survey of U.S. health economists on a series of questions ranging from mergers among health care providers to the profits of pharmaceutical manufacturers to fundamental health care reform. We find a high degree of agreement on issues of fact but considerable disagreement on issues that depend on values. Additional research may help to resolve some remaining disagreement about issues of fact but may do little to resolve disagreement over values. Results from this fall 2005 survey are compared with those from surveys conducted in 1989 and 1995.

Administrative Compensation of Medical Injuries: A Hardy Perennial Blooms Again

Barringer, P. J., Studdert, D. M., Kachalia, A. B., Mello, M. M. — 2008-07-10

Periods in which the costs of personal injury litigation and liability insurance have risen dramatically have often provoked calls for reform of the tort system, and medical malpractice is no exception. One proposal for fundamental reform made during several of these volatile periods has been to relocate personal injury disputes from the tort system to an alternative, administrative forum. In the medical injury realm, a leading incarnation of such proposals in recent years has been the idea of establishing specialized administrative "health courts." Despite considerable stakeholder and policy-maker interest, administrative compensation proposals have tended to struggle for broad political acceptance. In this article, we consider the historical experience of administrative medical injury compensation proposals, particularly in light of comparative examples in the context of workplace injuries, automobile injuries, and vaccine injuries. We conclude by examining conditions that may facilitate or impede progress toward establishing demonstration projects of health courts.

Administrative "Health Courts" for Medical Injury Claims: The Federal Constitutional Issues

Elliott, E. D., Narayan, S. A., Nasmith, M. S. — 2008-07-10

Our article analyzes whether the federal government may constitutionally supplant a traditional system of common-law trials before state judges and juries with new federal institutions designed by statute for compensating victims of medical injuries. Specifically, this article examines the federal constitutional issues raised by various proposals to replace traditional medical malpractice litigation in state courts with a federal system of administrative "health courts." In doing so, we address the following constitutional issues:

Is there federal authority to preempt state law (the commerce clause and spending clause issues)?

May jurisdiction be created in non - article 3 tribunals, and may claims be decided without trial by jury (the separation of powers and Seventh Amendment issues)?

Would pilot programs that require some claims to be pursued in a federal administrative forum while other claimants are left to pursue traditional state tort law remedies be constitutional (the equal protection issue)?

The article concludes that a federal compensation system through administrative health courts should be constitutional provided the statute is appropriately drafted and that appropriate factual findings are made concerning the benefits to patients and the public as well as to doctors and their insurers.

Federal Administrative Health Courts Are Unconstitutional: A Reply to Elliott, Narayan, and Nasmith

Widman, A., Hochberg, F. A. — 2008-07-10

This commentary responds to the essay by Elliott, Narayan, and Nasmith wherein they propose that the federal government may preclude plaintiffs with medically inflicted injuries from bringing state common-law tort claims against those whose negligence caused their injury. The administrative system championed by Elliott and other proponents is a radical departure from the current civil justice system. Specifically, we argue that the administrative health courts, as proposed, violate the commerce clause, the spending clause, the Seventh Amendment, and separation of powers principles. The commentary concludes that such a system is fatally flawed and cannot withstand constitutional scrutiny. Moreover, we are not persuaded that Congress will be able to ground such a radical constitutional restructuring in any sound public policy, as the majority of studies do not evidence Elliott, Narayan, and Nasmith's presumption that the civil justice system has failed in the medical malpractice context.

Comment on Marie Gottschalk's "Back to the Future? Health Benefits, Organized Labor, and Universal Health Care"

Robins, L. — 2008-07-10

Inclusion: The Politics of Difference in Medical Research

Fearnley, A. M. — 2008-07-10

Universal Health Insurance in France. How Sustainable?

Ham, C. — 2008-07-10

Health Care at Risk: A Critique of the Consumer-Driven Movement

Hall, M. A. — 2008-07-10

Books Received

2008-07-10

Contributors

2008-07-10

Editors' Note

Brown, L. D., Kraft, M. K. — 2008-05-09

Active Living and Biking: Tracing the Evolution of a Biking System in Arlington, Virginia

Hanson, R., Young, G. — 2008-05-09

In Arlington, Virginia, a steady evolutionary change in biking policy during the last three decades has yielded some of the nation's best biking assets. It has a comprehensive, well-connected, highly integrated, well-mapped, and well-signed system of shared-use paved trails, bike lanes, bike routes, and other biking assets, such as workplace showers. Understanding the conditions that led to Arlington's current biking system can provide lessons in the strategy and tactics of active-living politics.

One potentially effective political strategy that was successful in Arlington is for activists to pressure elected officials to select professional managers who see bikeways as crucial to the overall transportation system. Then it is important to formalize the government-citizen relationship through an advisory panel. Also, in Arlington, the incremental creation of biking assets helped create demand for more and better facilities. In turn, this created political support for expanding and upgrading. Finally, Arlington used potentially negative circumstances (e.g., the building of highway corridors, the introduction of the Metro) as opportunities to change the built environment in ways that have encouraged more active living.

Policy Influences on Community Trail Development

2008-05-09

This study explores processes and policies that facilitate the development of community trails. With funding from Active Living Research and the research framework of the Physical Activity Policy Research Network (PAPRN), we conducted a multiple-site case study. A total of six trails in Hawaii, Massachusetts, Missouri, North Carolina, South Carolina, and Washington were chosen for study. The goals of this case study were to identify the policy influences on trail development, explore the roles of key players in trail development, and compare and contrast findings from the different trails. Trail development can be a long process. Some of the trails took over a decade to complete because of funding, opposition, and roadblocks in the form of design standard policies. Work in trail development requires a team of many players, and it is necessary to balance their varied motives to accomplish a shared overall goal. Foresight through the master planning process is also a vital component of successful trail development. Finally, community involvement is key. Communities contemplating trail development should explore the effects of policy on the trail projects reported here to proactively identify potential influence.

Sustaining Active-Living Communities over the Decades: Lessons from a 1930s Greenbelt Town

Ahrentzen, S. — 2008-05-09

Greendale, Wisconsin, was intentionally created with many of the design and planning principles that active-living advocates promote today. This case study examines the processes behind sustaining these particular planning and design principles over time in light of economic and regional challenges that have faced not just Greendale but most town centers over the last fifty years. Despite these challenges, the walkable nature of Greendale's center remains strong today, in terms of both activity and community identity. While many circumstances are specific to this particular town, useful lessons can be drawn for those new urbanist (NU) communities being developed in greenfields and suburbs today, many of which are strikingly similar to Greendale — relatively small, low density, and located within metropolitan areas. Greendale's success resulted from (1) attending to the retail/commercial product mix; (2) attracting nonresidents to use the community's retail and public space; and (3) capitalizing on community investment not simply from residents' organizing efforts but, more important in this case, from corporate community involvement by a Greendale business firm whose interests and values coincided with those of the community.

The Promise of Wisconsin's 1999 Comprehensive Planning Law: Land-Use Policy Reforms to Support Active Living

Schilling, J., Keyes, S. D. — 2008-05-09

Weaving together the disciplines of planning and policy change with the emerging research of active living, this article explores the competing interests and underlying political forces behind the design and passage of Wisconsin's Comprehensive Planning Law of 1999. While Wisconsin's law remains a work in progress, it illustrates the contemporary policy battles over land use and smart growth and the resurgence of the property-rights movement. It further highlights the influence of smart-growth coalitions and policy networks on planning reform. The authors suggest that planning practitioners and active-living proponents can adapt and transfer these policy lessons from Wisconsin to address the complex relationships of the built environment, physical activity, and the nation's current obesity problem through state and local planning reforms.

Active Living as an Institutional Challenge: Lessons from the Robert Wood Johnson Foundation's "Celebrate Fitness" Program

Brown, L. D., Kraft, M. K. — 2008-05-09

Native American youth suffer disproportionately from a range of adverse health conditions. Empowering youth leaders to work on community-based solutions has proved effective in reducing tobacco use and gun violence and is now emerging as a promising approach to improving fitness and health. This article, based on direct observation and interviews with key informants, examines the implementation of a Robert Wood Johnson Foundation–funded project that gave tribal youth councils minigrants to design and run diverse projects that encourage physical activity in their communities. The article highlights the institutional challenges that confront health-promotion strategies for disadvantaged populations. Unless they take proper account of organizational, political, environmental, and cultural forces, funders' interventions have limited chances for success and sustainability.

Advocating for Active Living on the Rural-Urban Fringe: A Case Study of Planning in the Portland, Oregon, Metropolitan Area

Adler, S., Dobson, N., Fox, K. P., Weigand, L. — 2008-05-09

This case study is about the politics of incorporating active-living elements into a concept plan for a new community of about 68,000 people on the edge of the Portland, Oregon, metropolitan area. Development on the rural-urban fringe is ongoing in metropolitan areas around the United States. In this article, we evaluate the product of the concept-planning process from the standpoint of the extent to which environmental elements conducive to active living were included. We also analyze four issues in which challenges to the incorporation of active-living features surfaced: choices related to transportation facilities, the design and location of retail stores, the location of schools and parks, and the location of a new town center. Overall, the Damascus/Boring Concept Plan positions the area well to promote active living. Analyses of the challenges that emerged yielded lessons for advocates regarding ways to deal with conflicts between facilitating active living and local economic development and related tax-base concerns and between active-living elements and school-district planning autonomy as well as the need for advocates to have the capacity to present alternatives to the usual financial and design approaches taken by private- and public-sector investors.

Turning Brownfields into Greenspaces: Examining Incentives and Barriers to Revitalization

Siikamaki, J., Wernstedt, K. — 2008-05-09

This study employs interviews, document review, and a national survey of local government officials to investigate the factors that influence the success of efforts to convert underutilized contaminated properties into greenspace. We find that the presence of contamination continues to be a concern despite federal and state efforts to ease liability fears but also that site and project features can overcome this hurdle. In particular, jurisdictions appear more likely to convert distressed properties into greenspace if recreational parks, rather than open space, are planned, sites are already owned rather than available only through tax foreclosure, and the state is perceived as being supportive of the conversion. In addition, mixed public-private funding and site locations in residential areas are more likely to attract community support for conversion projects.

Collaborative School Planning and Active Schools: A Case Study of Lee County, Florida

Lees, E., Salvesen, D., Shay, E. — 2008-05-09

To contribute to the understanding of the links between urban planning and school siting and, ultimately, the impact of both on physical activity, we conducted a case study of Lee County, Florida. Our study examined the extent of state-mandated collaboration between the Lee County School Board and Lee County government (e.g., the Lee County Department of Planning, the Office of Smart Growth, and the Department of Parks and Recreation). Specifically, we investigated planning processes under mandated coordination between the school board and the county and the impact of such coordination on the integration of land-use planning and school facility planning. By describing the process of mandated collaborative school planning in Florida, we illustrate the promise and pitfalls of such top-down legislation and offer insights to other state and local governments looking for ways to improve local planning and to increase physical activity among children.

The Boston Schoolyard Initiative: A Public-Private Partnership for Rebuilding Urban Play Spaces

Lopez, R., Campbell, R., Jennings, J. — 2008-05-09

The Boston Schoolyard Initiative (BSI) is a policy effort to rebuild school yards in Boston through innovative citywide public-private partnerships. At the center of the initiative is a commitment to engage multiple stakeholders and utilize a bottom-up planning process to encourage meaningful change. Based on a case study of BSI, this article develops a framework to understand and analyze how different school and neighborhood sectors can partner to benefit neighborhood communities and utilize the built environment to encourage more active living and active learning. The article contributes to a literature that focuses on the effects of school yards and the role of physically active environments on learning. It expands on this literature by looking at the school-yard initiative as a way to build and expand relationships between teachers, parents, and the community at large. Finally, the study shows that even older schools in inner-city neighborhoods, previously considered blights, can be turned into community, educational, and political assets.

Contributors

2008-05-09

Editor's Note

Sparer, M. S. — 2008-03-05

A Road Map for Universal Coverage: Finding a Pass through the Financial Mountains

Sessions, S. Y., Lee, P. R. — 2008-03-05

Government already pays for more than half of U.S. health care costs, and nearly all universal health insurance proposals assume continued government involvement through tax subsidies and other means. The question of what specific taxes could be used to finance universal coverage is, however, seldom carefully examined, in part due to efforts by health care reform proponents to downplay tax issues. In this article we undertake such an examination. We argue that the challenges of relying on taxes for universal coverage are even greater than is generally appreciated, but that they can nevertheless be met. A proposal to fund a universal health insurance voucher system with a value-added tax illustrates issues that would arise for tax-financed plans in general and provides a broad framework for a bipartisan approach to universal coverage. We discuss significant problems that such an approach would face and suggest solutions. We outline a long-term political and legislative strategy for enacting universal coverage that draws upon precedents set by comparable legislative initiatives, including tax reform and Medicare. The results are an improved understanding of the relationship between systemic health care finance reform and taxation and a politically realistic plan for universal coverage that employs undisguised taxes.

Governance and Community Benefit: Are Nonprofit Hospitals Good Candidates for Sarbanes-Oxley Type Reforms?

Alexander, J. A., Young, G. J., Weiner, B. J., Hearld, L. R. — 2008-03-05

Recent investigations into the activities of nonprofit hospitals have pointed to weak or lax governance on the part of some of these organizations. As a result of these events, various federal and state initiatives are now either under way or under discussion to strengthen the governance of hospitals and other nonprofit corporations through mandatory board structures and practices. However, despite policy makers' growing interest in these types of governance reforms, there is in fact little empirical evidence to support their contribution to the effectiveness of hospital boards. The purpose of this article is to report the results of a study examining the relationship between the structure and practices of nonprofit hospital boards relative to the hospital's provision of community benefits. Our results point to modest relationships between these sets of variables, suggesting considerable limitations to what federal and state policy makers can accomplish through legislative initiatives to improve the governance of nonprofit hospitals.

Role of Budget Impact in Drug Reimbursement Decisions

Cohen, J. P., Stolk, E., Niezen, M. — 2008-03-05

There are three known criteria that underlie drug reimbursement decisions: therapeutic value, cost-effectiveness, and burden of disease. However, evidence from recent reimbursement decisions in several jurisdictions points to residual, unexplained variables, among which is budget impact. Budget impact refers to the total costs that drug reimbursement and use entail with respect to one part of the health care system, pharmaceutical care, or to the entire health care system, taking into account the possible reallocation of resources across budgets or sectors of the health care system. The economic and equity rationale for carrying out budget impact analyses is opportunity cost, or benefits forgone, measured in terms of utility or equitable distribution, by using resources in one way rather than another. In other words, by choosing to draw down the budget in one way, decision makers forgo other opportunities to use the same resources. Under a set of unrealistic assumptions, cost-effectiveness analysis accounts for opportunity cost while conveying to the decision maker the price of maximizing health gains, subject to a budget or resource constraint. However, the underlying assumptions are implausible, particularly in the context of pharmaceutical care. Moreover, budget impact analysis is more useful to the decision maker than cost-effectiveness analysis if the objective is not to maximize health gains subject to a budget or resource constraint, but to reduce variance in health gains. With respect to equitable distribution, budget impact analyses lay bare the individuals or groups who lose out — those who bear the opportunity cost of spending resources in accordance with one decision rule rather than another.

Balancing Regulatory Controls and Incentives: Toward Smarter and More Transparent Oversight in Long-Term Care

Miller, E. A., Mor, V. — 2008-03-05

Government oversight of long-term care involves inspections of patients' records, limited observations of patients and care practices, reviews of policies and procedures, and distribution of publicly available information. Although many providers bemoan the stifling consequences of excessive regulation, oversight in this area remains a highly legitimate endeavor for the public, though the public has limited trust in the existing regulatory regime. This distrust stems from many sources, not least of which includes considerable variation, both within and across states, in the way government oversight occurs. Reforming the current regulatory structure requires that we regulate "smarter" and more consistently. This means improving and maximizing use of the data already being collected, but it also means explicitly rationalizing the regulator's responsibility to review performance and apply sanctions when necessary. Oversight should more closely resemble consultancy, with regulators sharing information with providers about how to improve quality. Ideally, there needs to be an iterative process in which state inspectors identify performance problems and the nation's quality improvement organizations then help providers design quality improvement interventions to ameliorate the problems identified. The benefits of a revised regulatory approach are especially apparent in the aftermath of Hurricane Katrina, where more effective oversight would have identified nursing home residents at risk for low-quality care before the disaster occurred while better identifying those in need of evacuation or assistance afterward.

Alaska Public Health Law Reform

Meier, B. M., Hodge, J. G., Gebbie, K. M. — 2008-03-05

The Turning Point Model State Public Health Act (Turning Point Act), published in September 2003, provides a comprehensive template for states seeking public health law modernization. This case study examines the political and policy efforts undertaken in Alaska following the development of the Turning Point Act. It is the first in a series of case studies to assess states' consideration of the Turning Point Act for the purpose of public health law reform. Through a comparative analysis of these case studies and ongoing legislative tracking in all fifty states, researchers can assess (1) how states codify the Turning Point Act into state law and (2) how these modernized state laws influence or change public health practice, leading to improved health outcomes.

Attrition in the RAND Health Insurance Experiment: A Response to Nyman

2008-03-05

In a prior article in this journal, John Nyman argues that the effect on health care use and spending found in the RAND Health Insurance Experiment is an artifact of greater voluntary attrition in the cost-sharing plans relative to the free care plan. Specifically, he speculates that those in the cost-sharing plans, when faced with a hospitalization, withdrew. His argument is implausible because (1) families facing a hospitalization would be worse off financially by withdrawing; (2) a large number of observational studies find a similar effect of cost sharing on use; (3) those who left did not differ in their utilization prior to leaving; (4) if there had been no attrition and cost sharing did not reduce hospitalization rates, each adult in each family that withdrew would have had to have been hospitalized once each year for the duration of time they would otherwise have been in the experiment, an implausibly high rate; (5) there are benign explanations for the higher attrition in the cost-sharing plans. Finally, we obtained follow-up health-status data on the great majority of those who left prematurely. We found the health-status findings were insensitive to the inclusion of the attrition cases.

Health Plan Switching and Attrition Bias in the RAND Health Insurance Experiment

Nyman, J. A. — 2008-03-05

One of the most influential "lessons" of the RAND Health Insurance Experiment (HIE) is that cost sharing can reduce hospitalizations by about a quarter, with no effect on health for the average adult. In an earlier paper in this journal, I suggested that a portion of this reduction is due to participants becoming ill and dropping out of the experiment in order to switch to their preexperiment insurance coverage and thus avoid paying the cost-sharing amount. The sixteenfold higher voluntary attrition rate in the cost-sharing arms provides compelling evidence in support of this alternative explanation. Evidence is also provided by the finding in Manning, Duan, Keeler (1993) that the predicted number of hospitalizations among those who dropped out of the coinsurance arms was significantly greater by 34.5 percent than the actual number of hospitalizations, suggesting that participants anticipate hospitalizations and leave the experiment before incurring the cost-sharing payment. Still more evidence is provided by the finding that those (cost-sharing) participants with greater incomes, instead of being more likely to be hospitalized, as greater income usually implies, were less likely to be hospitalized than poor participants. This finding is consistent with their having better preexperiment insurance coverage than poor participants and therefore being more likely to have an incentive to drop out. This inpatient attrition bias makes it dangerous to rely on this lesson of the HIE, because it is not clear that hospitalizations were actually reduced by one-quarter, much less that if such a reduction actually had occurred, there would be no health consequences.

Misleading Congress about Drug Development: Reply

DiMasi, J. A., Hansen, R. W., Grabowski, H. G. — 2008-03-05

The review essay by Donald Light about a Congressional Budget Office report on pharmaceutical research and development (R&D) (Light 2007) contains factual errors, leaves the reader uninformed about rebuttal responses to criticisms made in the review about studies of R&D costs, and draws erroneous conclusions about the nature of industry economics.

Reply to DiMasi, Hansen, and Grabowski

Light, D. W. — 2008-03-05

Besides critiquing the Congressional Budget Office for failing to cite and discuss evidence from independent sources that suggest that the net corporate costs of pharmaceutical research and development costs are much lower than industry advocates claim, Light's review showed how these high estimates are constructed realities that one can reconstruct by using different assumptions, data, or calculations and come up with much lower estimates. In their reply here, DiMasi, Hansen, and Grabowski unwittingly reinforce that point.

The New Politics of the NHS: From Creation to Reinvention

Marmor, T. — 2008-03-05

The Prison and the Gallows: The Politics of Mass Incarceration in America

Wolff, N. — 2008-03-05

Growing Older in World Cities: New York, London, Paris, and Tokyo

Maddox, G. L. — 2008-03-05

The Truth about Health Care: Why Reform Is Not Working in America; The Health Care Mess: How We Got Into It and What It Will Take to Get Out; The Health Care Mess: How We Got Into It and How We'll Get Out of It

Peterson, M. A. — 2008-03-05

Health care reform is once again rising toward the top of the nation's political and policy agendas. Informed by three recent works on the subject, this review essay examines the recent history and reform climate as the country runs full throttle into the renewed debate. The central question is: will something not only, finally, succeed politically, but will it also be sensible substantively?

Books Received

2008-03-05

Contributors

2008-03-05

Editor's Note

Sparer, M. S. — 2008-02-05

Making the Case for School-Based Health: Where Do We Stand?

Silberberg, M., Cantor, J. C. — 2008-02-05

School-based health centers (SBHCs) have proliferated rapidly nation-wide and remain politically popular. This article explores the disconnect between the evidence and the discourse on SBHCs, drawing upon the authors' evaluation of SBHCs in Newark, New Jersey, and a critical assessment of the evaluative literature and public discourse on school clinics to argue that a number of important issues are being overlooked by both research and advocacy. These issues include variations in the health needs and health care resources of different communities and the questions of whether and how SBHCs can best integrate with existing resources to fill unmet local needs. Furthermore, despite the cautions of experts that third-party reimbursement (via traditional fee-for-service insurance or participation in health maintenance organizations) cannot cover clinic expenses and is difficult to obtain, pursuit of reimbursement continues to be a goal of some SBHC sponsors, helping to promote a clinic model that in some communities is very likely not to be the best way to address student needs or to build on clinic strengths. Discussion around SBHCs should focus on diagnosing specific community needs, identifying the best approach to meeting those needs, and seeking funding sources that match the work that needs to be done.

Preemptive Public Policy for Genomics

Carlson, R. J. — 2008-02-05

To many, genomics is merely exploitable technology for the leviathan of biotechnology. This is both shallow and short sighted. Genomics is applied knowledge based on profound and evolving science about how living things develop, how healthy or sick we are, and what our future will be like. In health care, genomics technologies are disruptive yet potentially cost-effective because they enable primary prevention, the antidote to runaway costs and declining productivity. The challenges to integration are great, however, and many bioethical and social-policy implications are alarming. Because it is poorly understood today, we must debate genomics vigorously if we are to act wisely. Public policy must lead.

A Temporal Analytical Approach to Decentralization: Lessons from Brazil's Health Sector

Gomez, E. J. — 2008-02-05

This article introduces a new concept to the study of decentralization processes: policy dynamism. At its core is the notion that the sequential and temporal process of health decentralization affect the nature of intergovernmental relationships and municipal bureaucratic capacity. Examining the case of Brazil, I argue that the rush to decentralize health services to municipalities has, in the absence of sufficient financial and technical assistance from the federal and state governments, increased state-municipal conflict over the management of health policy, limiting municipalities' ability to increase bureaucratic capacity. Consequently, some states have attempted to recentralize reforms, generating further conflict between both subnational levels of government. While some municipalities have tried to overcome these problems by creating associations and working with international organizations, several bureaucratic obstacles remain. This article attributes these outcomes not to federal institutions and economic constraints (the traditional approach in the literature) but rather to the noninstitutional, temporal policy dynamics of decentralization.

The Unintended Consequences of New Zealand's Primary Health Care Reforms

Gauld, R. — 2008-02-05

In 2001, the New Zealand government commenced a program to reform the organization of publicly funded primary care services. While there have been several positive results of this reform, including the reduction of patient co-payments and the extension of the range of primary care services, the government's program was a hastily implemented attempt to place primary care, the delivery of which is dominated by private doctors, under firm state control. It was also an attempt to override preexisting arrangements. As such, the government succeeded in its goal of establishing new primary health organizations (PHOs), but there were also significant unintended consequences. As detailed in this article, these consequences include (1) the creation of a labyrinthine funding and organizational system with a variable capacity to deliver on the government's reform objectives, (2) an increase in the power and scope of preexisting doctor organizations combined with a government unable to wrest control over the setting of patient co-payment levels, and (3) an emerging lack of clarity about future directions for the primary health care sector.

Black Markets: The Supply and Demand of Body Parts

Bard, J. S. — 2008-02-05

Black Markets: The Supply and Demand of Body Parts is an important contribution to the body of scholarship and policy analysis about one of the most difficult problems facing contemporary health policy, public health, and bioethics: the fact that the demand for donor organs far outstrips supply. In this book, Michelle Goodwin systematically reviews the general ways in which the United States' current organ-donation and transplantation system negatively affects potential donors and recipients, particularly African Americans. She proposes solving these problems by changing the current system that prohibits payment for organs to one that allows it. However, I argue that the entire discussion of a market-based solution to the problem of a shortage in supply in donor organs suffers from a flaw far greater than the inability to predict how such a market would work, because of a lack of reliable evidence that an offer of compensation would be effective in changing the minds of people who currently decline to donate the organs of their loved ones.

Better But Not Well: Mental Health Policy in the United States since 1950

Okma, K. G. H. — 2008-02-05

Books Received

2008-02-05

Contributors

2008-02-05