Private Law Alternatives to the Individual Mandate

Despite excitement on the left about a move to universal health care and on the right about a more state-driven model, major policy changes in a time of divided government are not imminent. Yet with the recent repeal of the individual mandate, the current system may be crumbling. The Affordable Care Act guarantees coverage to people with pre-existing conditions and prohibits insurers from charging them more than healthy people. But the mandate was supposed to draw cheaper and healthier people into the risk pools to balance out costs. Without the mandate, healthy people can simply wait to buy insurance until they get sick. Insurers are left to cover an increasingly sicker, more expensive population, and premiums skyrocket, starting a chain reaction ending in the so-called “death spiral.” The model only works if healthy people purchase insurance, and now there is little to prompt them to do so. This Article relies on private law to solve the problem. It looks to both neoclassical economic theory and principles of behavioral economics to better understand what motivates (and deters) the purchase of health insurance. It then explores economic incentives and “nudges” that will encourage healthy individuals to sign up for policies without forcing them to do so. It suggests co-opting practices previously deployed for nefarious purposes to prompt behavior that policy now seeks, such as insurers offering low introductory rates, long-term contracts, and limited exit rights. Other options include insurers selling return of premium-style policies or policies with a generosity frame, simplifying plan offerings, or automatically enrolling the uninsured but giving a right to opt-out. These private law solutions—many of which would not require congressional action—hold the promise of ultimately lowering prices without the government forcing action or taking away the right to make autonomous choices

Revisiting Incentive-Based Contracts

Incentive-based pay is rational, intuitive, and popular. Agency theory tells usthat a principal seeking to align its incentives with an agent\u27s should be able to simply pay the agent to achieve the principal\u27s desired results. Indeed, this strategy has long been used across diverse industries-from executive compensation to education, professional sports to public service-but with mixed results. Now a new convert to incentive compensation has appeared on the scene: the United States\u27 behemoth health-care industry. In many ways, the incentive mismatch story is the same. Insurance companies and employers are concerned about constraining the cost of care, and patients are concerned about quality of care. Physicians lack an adequate financial incentive to pay attention to either. Health care\u27s recent move away from the traditional fee-for-service compensation model to incentive pay is perhaps unsurprising

Contract Theory and the Failures of Public-Private Contracting

The market for public-private contracting is huge and flawed. Public-private contracts for services such as prisons and welfare administration tend to result in cost savings at the sacrifice of quality service. For instance, to cut costs, private prisons skimp on security. Public law scholars have studied these problems for decades and have proposed various public law solutions. But the literature is incomplete because it does not approach the problem through a commercial lens. This Article fills that gap. It considers how economic analysis of contract law, in particular efficiency theory and agency theory, bear upon the unique problems of public-private contracting. Public-private contracts are subject to systematic biases that cause the parties to impose a cost on service recipients in the form of low quality service. Because there is essentially no competitive market for these services, the contracting parties are not forced to internalize these costs. As a result, contracts tend to be underpriced. Thus, what appears to be a cost-saving mechanism is often, in fact, a systematic market failure. This Article proposes two unconventional and counterintuitive solutions to force the parties to internalize the cost of poor service provision. First, it suggests reading into public-private contracts a mandatory duty to act in furtherance of the public interest. Although efficiency theory assumes that mandatory restrictions on contracting parties are inefficient, a mandatory rule is justified, here, because the law must protect non-parties to the contract who cannot adequately protect themselves. Second, this Article argues, based on behavioral economics studies, that these contracts should be less detailed. Although agency theory suggests that detailed tasks, performance incentives, and monitoring mitigate agency costs, those mechanisms do not work with public-private contracts. Studies indicate that less detailed contracts that rely on social norms such as reciprocity may better align incentives

Randomized trial comparing daily interruption of sedation and nursing-implemented sedation algorithm in medical intensive care unit patients

Introduction Daily interruption of sedation (DIS) and sedation algorithms (SAs) have been shown to decrease mechanical ventilation (MV) duration. We conducted a randomized study comparing these strategies. Methods Mechanically ventilated adults 18 years old or older in the medical intensive care unit (ICU) were randomly assigned to DIS or SA. Exclusion criteria were severe neurocognitive dysfunction, administration of neuromuscular blockers, and tracheostomy. Study endpoints were total MV duration and 28-day ventilator-free survival. Results The study was terminated prematurely after 74 patients were enrolled (DIS 36 and SA 38). The two groups had similar age, gender, racial distribution, Acute Physiology and Chronic Health Evaluation II score, and reason for MV. The Data Safety Monitoring Board convened after DIS patients were found to have higher hospital mortality; however, no causal connection between DIS and increased mortality was identified. Interim analysis demonstrated a significant difference in primary endpoint, and study termination was recommended. The DIS group had longer total duration of MV (median 6.7 versus 3.9 days; P = 0.0003), slower improvement of Sequential Organ Failure Assessment over time (0.70 versus 0.23 units per day; P = 0.025), longer ICU length of stay (15 versus 8 days; P \u3c 0.0001), and longer hospital length of stay (23 versus 12 days; P = 0.01). Conclusion In our cohort of patients, the use of SA was associated with reduced duration of MV and lengths of stay compared with DIS. Based on these results, DIS may not be appropriate in all mechanically ventilated patients

Anti-Stokes luminescence cooling of Tm3+ doped BaY2F8

We report laser-induced cooling with thulium-doped BaY2F8 single crystals grown using the Czochralski technique. The spectroscopic characterization of the crystals has been used to evaluate the laser cooling performance of the samples. Cooling by 3 degrees below ambient temperature is obtained in a single-pass geometry with 4.4 Watts of pump laser power at lambda = 1855 nm

Organic–inorganic interfaces and spiral growth in nacre

Nacre, the crown jewel of natural materials, has been extensively studied owing to its remarkable physical properties for over 160 years. Yet, the precise structural features governing its extraordinary strength and its growth mechanism remain elusive. In this paper, we present a series of observations pertaining to the red abalone (Haliotis rufescens) shell's organic–inorganic interface, organic interlayer morphology and properties, large-area crystal domain orientations and nacre growth. In particular, we describe unique lateral nano-growths and paired screw dislocations in the aragonite layers, and demonstrate that the organic material sandwiched between aragonite platelets consists of multiple organic layers of varying nano-mechanical resilience. Based on these novel observations and analysis, we propose a spiral growth model that accounts for both [001] vertical propagation via helices that surround numerous screw dislocation cores and simultaneous 〈010〉 lateral growth of aragonite sheet structure. These new findings may aid in creating novel organic–inorganic micro/nano composites through synthetic or biomineralization pathways

Synthesis and evaluation of ultra-pure rare-earth-coped glass for laser refrigeration

Significant progress has been made in synthesizing and characterizing ultra-pure, rare-earth doped ZIBLAN (ZrF{sub 4}-InF{sub 3}BaF{sub 2}-LaF{sub 3}-AlF{sub 3}-NaF) glass capable of laser refrigeration. The glass was produced from fluorides which were purified and subsequently treated with hydrofluoric gas at elevated temperatures to remove impurities before glass formation. Several Yb3 +-doped samples were studied with degrees of purity and composition with successive iterations producing an improved material. We have developed a non-invasive, spectroscopic technique, two band differential luminescence thermometry (TBDLT), to evaluate the intrinsic quality of the ytterbium doped ZIBLAN used for laser cooling experiments. TBDLT measures local temperature changes within an illuminated volume resulting solely from changes in the relative thermal population of the excited state levels. This TBDLT technique utilizes two commercially available band pass filters to select and integrate the 'difference regions' of interest in the luminescence spectra. The goal is to determine the minimum temperature to which the ytterbium sample can cool on the local scale, unphased by surface heating. This temperature where heating and cooling are exactly balanced is the zero crossing temperature (ZCT) and can be used as a measure for the presence of impurities and the overall quality of the laser cooling material. Overall, favorable results were obtained from 1 % Yb3+-doped glass, indicating our glasses are desirable for laser refrigeration