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This chapter traces the path of competition law in health care and explains its chicken-and-egg relationship with provider organizational arrangements. It explores a central puzzle for future health care policy: Why have market forces failed to counteract organizational fragmentation? Answering this question requires an understanding of how competition policy is inexorably linked to the organizational architecture of health care and how the fragmentation that bedevils those arrangements has undermined its success. The chapter concludes with a negative assessment of recent consumer-driven approaches, finding them likely to increase fragmentation and incapable of delivering the benefits of competition.

This chapter focuses on the need for more targeted assessment of the impact of market forces on communities. Pilot programs encourage experimentation in the delivery system without risking widespread disruption of care for the uninsured and emergency services. The Center for Medicare & Medicaid Services (CMS) has already embraced the idea of pilot programs in other contexts, and they could be especially appropriate if specialty hospitals were permitted in markets where general hospitals had a demonstrably poor record of community service. In such markets, cross-subsidization is probably already low, and specialty hospital threats to it are not as much of a concern as they are in areas where general hospitals consistently serve a substantial base of indigent and uninsured patients. Part II of the chapter makes the case for pilot programs by laying out basic facts about the current performance of specialty hospitals. Part III describes the increasingly complex legal landscape surrounding them—including directly applicable provisions of state and federal laws, and incumbent hospitals' strategies to deploy other regulations, statutes, and common law to gain competitive advantage. After briefly describing the drawbacks of all these strategies, Part IV advances the positive contribution of the chapter: a turn to pilot programs that would promote an evidence-based response to the rise of specialty hospitals.

This chapter addresses the past four decades of American health care politics, asking whether the idea of fragmentation provides a central and helpful analytical perspective. Part I reviews the highlights of health policy disputes from the 1970s to the 2000s. Part II places the United States in comparative perspective. Part III discusses the regulation versus competition debate that has been such a dominant part of American medical care discussion since the 1970s. Part IV discusses the issues raised by efforts to reform Medicare, and questions whether the theme of fragmentation illuminates those policy disputes. Part V concludes that fragmentation refers to many disparate features of American medical care and politics, and is illuminating only when tied to specific institutions, internests, and ideas.

This chapter argues that although concern for individuals with relatively high expected health care costs may justify significant cross-subsidization on normative grounds, it makes sense as a matter of fairness and in terms of minimizing attendant efficiency losses to sever the employment link, enacting a program through which cross-subsidization occurs within society more generally. The chapter is organized as follows. Section 2 briefly reviews the literature on labor market distortions related to health insurance benefits. Section 3 discusses how many individuals are likely to be “uninsurable” in an insurance market in which coverage is not tied to a person's employer. Section 4 lays out the proposal to move individuals requiring subsidies to a broad-based pool financed through the federal tax system, and discusses the determinants of health insurance affordability and pricing mechanism. Section 5 discusses the necessary federalization of Medicaid and the abolition of state-level insurance mandates that accompany our proposal. Section 6 examines the experience of other countries in order to shed light on the efficacy of our proposal, and Section 7 concludes.

This chapter details events in Josephine Roche's life from 1935 to 1939. Despite her many other roles, Roche's primary obligation in the New Deal government was oversight of health policy. She fulfilled that obligation in two ways. Within the Treasury Department, she took charge of the Public Health Service at a moment of explosive growth, championing a vastly expanded mandate for the agency and building a more effective public health infrastructure in the states. Outside the Treasury, she spearheaded a campaign to elevate health care to the status of a “basic American right.” In the course of that campaign, Roche patched together a national health plan, which she used to generate a nationwide conversation about the role of the federal government in health care.

This chapter discusses the financing aspect of health-care planning. It outlines the pressures that have led to the current interest in health-care financing, and argues that country-specific analysis of these pressures needs to be undertaken by planners as a basis for policy formulation. Criteria for assessing funding mechanisms are introduced, and the major alternatives for financing health care are described. Recent developments in the way in which external support is provided are discussed.

This chapter explores the methodological questions raised by concerns about weaknesses in international comparison in health policy. The core question is how one nation can learn from another competently in health care policy. The chapter is organized as follows. The first section describes the political context of health and welfare state reform debates during the last three decades of the twentieth century. The second section takes up the topic of cross-national policy learning more directly, addressing some of the promises and methodological pitfalls of such work. The third section focuses on health reform debates, reviews the claims of convergence among industrialized countries, and outlines the expansive scholarship on comparative health policy. The fourth section addresses the purposes, promises, and pitfalls of comparative studies in health policy. The fifth section groups the works in categories that highlight the character, possibilities, and limits of this comparative literature. The concluding section returns to the chapter's basic theme: the real promise of comparative policy scholarship and the mixed portrait of performance to date.

This chapter examines heath care reform in Germany. It begins with a brief description of the German health care system and its operation—its political dynamics and its recent evolution. It then turns to the role of evidence and learning in general and in the German context in particular, citing examples of evidence versus interests and power as guiding principles in the policy-making process and of cross-border learning for and from the German experience.

Hospitals across countries face common pressures of changing ideology, shifting consumer demand, and financial and budgetary pressure. This chapter addresses the question of whether such common pressure also leads to similar policy directions and organizational change. It examines the experience of five industrialized countries: the United States, Canada, Germany, the Netherlands, and the United Kingdom.

This chapter considers the role of health care systems in generating poverty and inequality. It argues that health care systems, as social institutions, are built out of the existing social structure and carry its inequalities within them. However, health care systems are also a key site for contestation of existing inequality: they offer a representation back to us of our societies' capacity for care, and a public space for reworking those capacities. Effective health care reform that seeks to make the social institutions of health care more equitable must draw from an effective theory of health care system/inequality interaction. An approach to conceptualizing health care reform is presented.

This chapter surveys the strategies, tactics, and results of US efforts to change health care policy. It begins by discussing the international health policy agenda in the mid-1990s. It identifies American intellectual trends at the time and how they related to international discourse. It then raises some doubts about how accurately the discourse in the United States and abroad represented practice. Next, it reviews what happened in the United States between 1996 and 2005. For a short time, “market” approaches seemed to be improving the rationality and performance of American health care. Yet that pattern soon reversed, and even when there were savings, they did not work in the way the rhetoric of the time suggested.

This chapter analyses the Europeanization of German social policy, focusing on the sectors of old-age pensions and health care. It begins by establishing the specific properties of German social policy from a cross-national perspective. This will be done for the mid-1970s, hence prior to any major potential direct or indirect EU effect. Next, the chapter reviews the potential European, global, and domestic pressures on old-age pension arrangements and health care. It contextualizes social policy development to isolate EU integration as a variable from other factors such as demographic change (‘greying’ of the society), individualization, technological change, German unification, and economic and financial globalization, which may point in similar directions. The major part of the discussion reviews the development of German pension and health care policy over the last decades, and analyses the extent to which these developments can be attributed to EU integration.

In recent decades, the development of the long-term care (LTC) policies in the United States has lagged behind the growing care needs of older persons with chronic illnesses and mental or physical disabilities, and their families. In most industrialized societies, the responsibilities for social policy and service delivery are seen as shared by the household, the state, and the marketplace. In these societies, an assurance of government involvement to protect an individual's minimum standard of living when the market fails to do so, is an important policy principle. A policy based on a balanced and complementary system between the private (market and household) and public sectors is often sought by progressive reformers. However, in the United States, LTC polices are lopsided, with the responsibility for LTC provision primarily placed on the elder's household. This chapter examines the development of federal and state policies affecting LTC, namely, nursing homes and other providers of such care. It presents relevant issues surrounding LTC vis-à-vis the political, social, and economic changes in U.S. society.

This chapter focuses on public health policy regarding end-of-life care in sub-Saharan Africa (SSA). There is an overwhelming need for quality palliative care services across SSA. Centres of excellence exist and enormous advocacy gains have been made. Lessons have been learnt in terms of coverage, lobbying and advocacy, and innovative low cost integrated palliative care in an unpredictable trajectory that can be useful for other regions of the world. However, palliative care remains a public health priority within the region and practitioners need to continue to be innovative, adapting and developing appropriate models of care that best meet the public health needs for all.

This chapter provides a detailed review of issues related to end-of-life care. Specific attention is focused on financing the care of dying elders, including information on how care is paid for, the gaps and limitations in coverage, and relevant regulations and policies impacting end-of-life care options. Disparities in care at the end of life are examined. Attention is also focused on cultural factors that influence elders' care decisions. Ethical and legal issues related to end-of-life care for the elderly are addressed, including advanced directives and assisted suicide. The chapter concludes with policy recommendations to improve care at the end of life.

Many U.S. states have recognized the need for reliable data-driven information to plan and implement health-care policy. However, these needs have been difficult to meet because data are typically gathered and stored in separate data systems geared to support distinct programs or applications. Despite having huge amounts of health data, few states have been able to leverage the data in their holdings to link information across databases and produce useful analyses. Such data linkages typically allow information on a particular person from one data system to be linked with information about that same person from another system. With linked data, it is possible to make use of information that already exists to gain a better, more comprehensive understanding of health status, service use, market patterns, expenditures, and health outcomes. This chapter reviews linkage and other ways of combining data, approaches that have enormous potential to enhance the portfolio of health statistics we create, to provide perspective on the health of populations and the factors that influence the patterns we observe, and to enhance dissemination of health statistics that will improve the approaches we use to make improvements in health.

Contemporary U.S. health care is characterized by the under-use of services known to improve patients’ outcomes and the over-use of services beyond what can benefit patients. Large proportions of Americans are not receiving treatment that is in accordance with evidence showing what works best for their conditions. The situation is allowed to continue because of payment policies that reimburse physicians and hospitals for the services they deliver on the basis of volume rather than appropriateness, evidence of effectiveness, or value. Our outlays for health insurance premiums, deductibles, and co-payments are buying us suboptimal medical care. If more and better comparative effectiveness research is to increase the value of the dollars we spend on health care, patients, providers and third party payers must become better students of medical evidence, and payment policies and the organization of health services must be reconfigured to align medical care with evidence.

This chapter first describes the key elements of “comprehensive long-term care (LTC) policy” and makes the case that it is a reasonable policy target for advanced industrial nations. Second, it discusses the two “ideal models” for comprehensive LTC: direct public services and social insurance. Third, it analyzes the policy process. It examines how Japan first opted for direct services and then switched to an approach similar to Germany. Fourth, it turns to comparative analysis to try to explain how and why the Japanese program differs from that in Germany.