Wanting It All: The Challenge of US Health System Reform

This is the published version

Canada\u27s Supreme Court and Its National Health Insurance Program: Evaluating the Landmark Chaoulli Decision from a Comparative Perspective

This article proceeds in three modes. The first briefly characterizes my reactions to the Chaoulli decision in June 2005 as a policy analyst and one of the experts in the Quebec trial testifying on behalf of Canada\u27s Attorney General. The second part discusses some of the commentaries of others in connection with this decision. The third-and the main section-deals with the Court majority\u27s use of international evidence in arriving at its decision and argues that the approach taken violated almost every scholarly standard for competent, cross-national policy analysis

Canada\u27s Supreme Court and Its National Health Insurance Program: Evaluating the Landmark Chaoulli Decision from a Comparative Perspective

This article proceeds in three modes. The first briefly characterizes my reactions to the Chaoulli decision in June 2005 as a policy analyst and one of the experts in the Quebec trial testifying on behalf of Canada\u27s Attorney General. The second part discusses some of the commentaries of others in connection with this decision. The third-and the main section-deals with the Court majority\u27s use of international evidence in arriving at its decision and argues that the approach taken violated almost every scholarly standard for competent, cross-national policy analysis

How Not to Think About Managed Care

The claim of this Article is that the concept of managed care, like many concepts now prominent in commentary about medical care finance and delivery in the United States, is incoherent and thus a barrier to useful analysis. To demonstrate this conclusion, we first discuss the managerial context in which managed care claims have arisen and outline the diverse trends to which the category is regularly and confusingly applied. We then suggest an alternative approach to characterizing recent changes in medical care and show how this approach alters and deepens our understanding of recent economic and political developments. We conclude by arguing for more neutral categories to make sense of past and projected developments in methods of reimbursement, techniques of management, and organizational structures

A New Look at Nonprofits: Health Care Policy in a Competitive Age

The importance of organizational form in American medicine has been the subject of much debate. But the character of the debate-the nonprofit form versus its competitors-has been sufficiently confused that much of the controversy should be reconsidered. That debate has been both ideological (commercialism and profit versus service and professionalism) and practical (which form is more efficient)? The challenge of public policy is to adapt public rules to the central realities of American medicine, not the shibboleths of shrill discourse. In the case of medicine, factors other than the form of legal ownership-among them, the nature of the service provided, the developmental stage of the service, the role of physicians in providing the service, and the nature of government regulation-are more important in fashioning those appropriate responses

From HMOs to ACOs: The Quest for the Holy Grail in U.S. Health Policy

The United States has been singularly unsuccessful at controlling health care spending. During the past four decades, American policymakers and analysts have embraced an ever changing array of panaceas to control costs, including managed care, consumer-directed health care, and most recently, delivery system reform and value-based purchasing. Past panaceas have gone through a cycle of excessive hope followed by disappointment at their failure to rein in medical care spending. We argue that accountable care organizations, medical homes, and similar ideas in vogue today could repeat this pattern. We explain why the United States persistently pursues health policy fads--despite their poor record--and how the promotion of panaceas obscures critical debate about controlling health care costs. Americans spend too much time on the quest for the "holy grail"--a reform that will decisively curtail spending while simultaneously improving quality of care--and too little time learning from the experiences of others. Reliable cost control does not, contrary to conventional wisdom, require fundamental delivery system reform or an end to fee-for-service payment. It does require the U.S. to emulate the lessons of other nations that have been more successful at limiting spending through budgeting, system wide fee schedules, and concentrated purchasing