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This chapter deconstructs gender differences to explore the contested issues surrounding gender difference, when the politics of presence converged with partisan politics in the struggle over health care reform during the Democratic-controlled 103rd Congress. The impact of the institutional environment on women’s agenda and actions, along with differences in environmental pressures across parties and committees, are explored. The analysis attempts to move beyond the simple question of whether women make a difference to an understanding of how political environments, structured by partisanship and steeped in masculinist values, affect and can be affected by the feminale. The case study suggests that one cannot truly understand gender differences in an institutional vacuum, even as it forces us to confront the relationship between gender difference and substantive representation of women, and to consider the value of the concept of feminist protest in understanding partisan differences in gender difference and women’s impact.

In this second of three chapters on the distinctive policy dynamics of particular areas of social provision, Susan Giaimo addresses the issue of whether the success of the reformed welfare state in the shape of payers’ and policy makers’ cost‐containment projects have had as their price the sacrifice of equity and solidarity. These questions are explored through the lens of health care reform in Britain, Germany, and the US since the late 1980s: each a country with a distinctive health care system, which undertook major reform initiatives designed to control health care outlays, and addressed the efficiency and equity goals in markedly different ways. Section I provides a broad background to situate the contemporary politics of health care reform, explaining how and why health care systems in Western countries have come under the stress of increasing cost pressures even as governments and employers have become more apprehensive about the possible effects of the welfare state on economic competitiveness. Section 2 develops the argument in greater depth, explaining how existing health care and political systems provide different opportunities or constraints for payers and the state to pursue unilateral cost‐containment strategies, how health care institutions themselves shape policy preferences and strategies of payers, and how some systems require compromise solutions that reconcile equity with efficiency. Section 3 presents each country's case, and the concluding section considers the broader lessons from health care reform for the contemporary politics of welfare state adjustment.

This chapter examines the ideational and political movements advocating market-based forms of delegated governance since the 1970s. In part, the embrace of marketizing reforms reflected the refinement of ideas about the inefficient and oppressive nature of government as juxtaposed with the dynamism, efficiency, and liberating qualities of markets and individual choice. Some conservative and centrist policy-makers also believed the American state was inherently weak—a self-fulfilling prophecy given their longstanding resistance to building effective bureaucratic capacity at the federal level. In a context of rising health care costs, some policy-makers sought ways to make private insurers do the tough work of disciplining health care interests, delegating to these non-governmental authorities responsibility for meting out pain to medical providers. We trace this impulse through the push for allowing HMOs to administer Medicare benefits; the gathering enthusiasm for managed competition and the Clinton health care reform effort of 1993/94; proposals that emerged in the 1990s for complete Medicare voucherization; and the movement for Health Savings Accounts.

This chapter summarizes the book’s main findings and probes its larger implications. The book has not only shed light on an important episode in American politics, but advanced our thinking about the complex realities of the American state. A second set of implications has to do with the nature of redistributive policy in the United States, which some would argue has been captured by well-heeled interests and become increasingly unresponsive to mass opinion. To the contrary, the book has argued that because the public sends fundamentally contradictory signals to American politicians about what the role of government should be in their lives, delegated arrangements often reflect the views of an ambivalent public. Moreover, because deeply-rooted ideational and institutional forces have driven the recourse to these kinds of governing arrangements again and again, one can expect this pattern to continue in the foreseeable future. To show this, the book ends with a brief examination of the 2009-2010 health care reform effort in which both the fight over the appropriate scope and power of the federal government and the solution—delegation to private health insurers and states—reflect the political forces traced in this book.

Many countries, including the United States, lack consensus about the core ethical principles concerning health and health care, beyond a market‐based approach to resource allocation. This chapter offers a normative theory for analyzing health policy decisions and recognizes that norms need fundamental restructuring to address existing health problems. Substantive normative principles (moral legitimacy) should be introduced into deliberative democratic process (political legitimacy) for a comprehensive, integrative theory of health and social justice. The chapter reviews the role of moral values in motivating citizens' support for public policies, and explores differences between social agreement frameworks such as incompletely theorized agreements (ITAs) and overlapping consensus and more traditional political bargaining models. ITA analysis of the American Clinton health care reform attempts reveals agreement on the mid‐level concept of universal coverage, but disagreement on both high‐ and low‐level principles. The chapter concludes that high‐level principle (e.g. health for all) or low‐level principle (e.g. willingness to pay for other's and future selves' health insurance) agreement, arising from internalization of shared public moral norms, might lead to more stable support for reform.

This chapter presents an evaluation of the alternative explanations of the American case based on the historical evidence given, and analyzes the prospects of health care reform in the twentieth century. It also argues that the United States does not have the health care system it needs due to the failure of its citizens to realize how much they have ceded their health care to private interests, and also reviews the theories of the welfare state.

Globally, post-Alma Ata health care system reforms have included reorganization of government health agencies, establishment of rationalized, evidence-based systems of care, implementation of user charges for public services, and experiments with third party financing. Drawing on materials collected in the context of long-term ethnographic research in Mongolia, this chapter reveals that there is a mismatch between the economic rationality that underlies current health reform programs and the realities of the lived experiences of illness in poor communities. Coupled with decentralization and poor regulatory oversight, current health reform efforts can result in fragmentation of the health system, increasing opportunity costs for health care seeking by poor households, reduced access to essential drugs, and an overall increased risk for health-cost related impoverishment. The chapter concludes by arguing that ethnographic information on health care seeking in poor communities can inform health reform efforts through explaining how features of health reform produce health inequities.

This chapter considers how government can influence the organization of the health-care delivery system. It begins by defining the meaning of “an organization”—as a provider of health-care services—and that of “the organization of the system.” It then describes three kinds of interventions: changes in who-does-what, changes in incentives, and managerial changes, and discusses how they can improve overall performance. These interventions must work together; incentive changes like decentralization or contracting will not alter outcomes unless accompanied by changes at the managerial level. Similarly, the potential cost savings and clinical quality gains from changing scale and scope will only be realized if managers take advantage of their opportunities. Ultimately, the behavior of front-line workers and their managers has to be changed to produce real improvement.

This introductory chapter discusses health sector reform. It argues that economic, social, and political forces, both inside and outside the health-care system, are causing widespread pressures to spend more on health care. New technologies (including new drugs) as well as changes in population structure and disease patterns are continuing to push up per capita health-care costs. The evolving international economic system often limits the capacity of governments and the private sector to meet these higher costs, especially in poor countries, because of short-term crises and longer-term competitive pressures. Broad shifts in intellectual beliefs about the state and the market have led to widespread promotion of market competition and privatization as solutions for all economic problems, including policies for the health sector.

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.

This chapter examines the Dutch health care reform experience, focusing on how managers in Dutch health insurance and health care have addressed the challenges of a rapidly changing business environment. It starts with a brief description of health care in the Netherlands at the beginning of the twenty-first century. It then discusses the (only partially implemented) reform proposals of the 1980s and 1990s. It also describes how government policy interacts with the behavior of groups affected by that policy.

In the United States, health care reform calls for a realignment of physician roles to include (a) teamwork and interdisciplinary collaborative care, (b) continuing education and lifelong learning, and (c) workplace learning. Embedded in these constructs are the principles of shared decision making and patient-centered care. A sizable shift in the concept of the “medical school” is described to enable greater attention to lifelong and workplace learning, and in support of interprofessional care. To accomplish this broad goal, faculty development is needed to address the changes required in a patient-centered health environment. This requires institutional reorganization and integration, increasing the use of human, technological, and clinical resources from clinical, educational, and research entities within an integrated and functional, effective academic medical center. Such shifts will require thinking along an integrated educational continuum, not only from the standpoint of admissions to a health professional career to retirement, but also across health professional divisions. Finally, a shift to patient-centered care requires reform in educational methodology: an increased use of a wide variety of educational tools and methods as well as more focus on measurable and meaningful uptake of content and less on the process of the simple dissemination of information.

This chapter uses the Canadian health policy experience to illuminate the conditions under which fundamental or incremental reform takes place. The chapter is organized as follows. The first section briefly sets out the theoretical framework for thinking about the dynamics of change in the health care arena. The second reviews the organizational and financial structures of Canadian health care in the 1970–1995 period, and addresses in particular the themes of the 1996 Four Country Conference: managing change, consumer choice, and resource allocation. The third section assesses the system in the mid-2000s and notes what remains constant and what has changed between 1996 and 2008.

Financing has an extremely important impact on the performance of a health system. It determines how much money is available, who bears the financial burden, who controls the funds, how risks are pooled, and whether health-care costs can be controlled. These factors, in turn, help determine who has access to care, who is protected against impoverishment from catastrophic medical expenses, and the health status of the population. All the money raised through any financing method (except for foreign contributions) comes, directly or indirectly, from citizens. Each nation has to decide is what sources to use, and to what extent. This chapter addresses these questions. It lays out the key criteria to be used when a nation considers which combination of financing methods may be best suited to it. It argues that the mixture does and should depend greatly on social values and politics. It then describes the different methods of financing and discusses their advantages and disadvantages. It considers the question of how to allocate the funds that the financing system generates. The chapter concludes with some conditional advice about which financing schemes are feasible for countries at different stages of socioeconomic development.

This chapter discusses whether and how payment policy can be an effective tool for improving health care delivery and whether past and present payment reforms will lead to better and more affordable health care. Focusing on Medicare, the chapter sketches out the theoretical framework that health economists use to examine provider payment and summarizes the empirical tests of this theory. It then summarizes the evolution of Medicare from cost-based to prospective reimbursement and its entry into value-based purchasing and assesses whether payment policy is making progress. The chapter concludes that on the whole, efforts to transform health care by mobilizing or redirecting competition through consumers are problematic owing to the limits of patient expertise and hidden information and actions by providers. Finally, addressing the question of whether it is possible to get payment “right,” the chapter concludes that as long as payment for physician services is based on a fee schedule and each provider is in its own silo, cost control will remain extremely difficult.

The chapter begins with a review of the efforts to reform health care in ways that would assure health care for all Americans, beginning with Progressive Era reforms in the early 1900’s through the William Clinton administration’s ill-fated Health Security Act in the early 1990’s. After delving into the less ambitious reforms of late 1900’s aimed at cost-containment and incremental expansions of health insurance coverage for low-income children, the chapter examines the devolution of the employment-based insurance for working families was pivotal to the economic and political context of the Affordable Care Act (ACA) of 2009 –the first federal legislation in U.S. history to advance universal health insurance for all American citizens as its central goal. The chapter concludes with a prognosis for the successful implementation of the ACA, as well as its long term prospects.

This chapter provides an introduction to the policy cycle for health-sector reform. It discusses the six stages of the process: problem definition, diagnosis, policy development, political decision, implementation, and evaluation.

This chapter considers the role of health care in health inequalities debates. Drawing on international literature concerning equity within health systems, it first (briefly) outlines the evolution of the NHS in the UK, including post-devolution divergence between England, Northern Ireland, Scotland, and Wales. It then considers the recent (much contested) health care reforms in England from an equity perspective, arguing that funding restrictions currently appear to represent the greatest threat to equity. Whilst acknowledging that health care is only one of a complex array of factors that influence health inequalities, the chapter challenges the tendency of health inequalities researchers to regard a focus on health care as a distraction from a more appropriate emphasis on the social determinants of health, making the case for the need to develop stronger links between research concerning health (care) systems, and research focusing on health inequalities and the social determinants of health.