Pragmatism is beginning to trump ideology in Europe’s ‘public-private’ debate over healthcare

The merits of public vs private healthcare have traditionally formed one of the key ideological divisions between European political parties. Richard B. Saltman writes that while this debate has often been exceptionally heated, over the last few decades a number of European countries have started to take a more pragmatic approach in terms of both the use of private healthcare and the operating philosophy adopted in public hospitals. Although the public-private debate is unlikely to ever disappear entirely, these trends and the pressures of prolonged austerity have steadily reduced its relevance to actual service delivery

In the current bitterly contested political atmosphere, theSupreme Court’s second decision on Obamacare has resolvedlittle

This week, the Supreme Court ruled in favor of subsides which support federal health insurance exchanges which operate in the states under the Affordable Care Act. Richard B. Saltman writes that the core argument over Obamacare goes beyond the role of these subsidies and that many who oppose it do so on the grounds that it is an expensive federalization of health care. He argues that the Supreme Court has clearly and intentionally misread the clear and intentional language of the Affordable Care Act, and in doing so has only moved the controversy and debate on to the 2016 Presidential election

There is little common ground between the two opposing moral narratives on the implementation of Obamacare

Two weeks ago on 1 October, the 2010 Patient Protection and Affordable Care Act (ACA) began implementation, despite the government’s shutdown due to disagreements between the Republican and Democratic parties over its funding. Richard B. Saltman looks at the two opposing moral narratives over the ACA: one which focusses on the program’s health benefits, and a second which argues that the ACA represents a fundamental political and bureaucratic threat to the continued decentralized governance and economic future of America. Past experience with similar clashes between completely different moral narratives indicates that the US may well be in for a long-term war of political attrition over the ACA

The implementation of the Affordable Care Act has undermined public trust in government

The botched roll-out of government health insurance exchanges has trained a harsh spotlight on the Affordable Care Act. While the health law’s impact on the economy remains sharply disputed, Richard B. Saltman argues that politically motivated implementation decisions – from disruptions of existing insurance coverage to special treatment for labor unions and favored industries – have deepened a legitimacy crisis for government in general. He writes that as levels of citizen trust in government reach an all-time low, the ability of either party to make policy is diminished

The financial crisis means that Europe will need to look beyond the public sector to provide its healthcare needs

The financial crisis has led to public spending cuts across most European countries. Richard B Saltman and Zachary Cahn write that even if current levels of health spending are maintained, public healthcare systems will increasingly come under strain due to projected rises in healthcare costs. They argue that the only solution left for European governments is to increase the contribution made by other sources of care, such as those in the private and voluntary sectors

Lessons from the TAPS study - Management of medical emergencies

The Threats to Australian Patient Safety (TAPS) study collected 648 anonymous reports about threats to patient safety by a representative random sample of Australian general practitioners. These contained any events the GPs felt should not have happened, and would not want to happen again, regardless of who was at fault or the outcome of the event. This series of articles presents clinical lessons resulting from the TAPS study.3 page(s

Governance, Government, and the Search for New Provider Models

A central problem in designing effective models of provider governance in health systems has been to ensure an appropriate balance between the concerns of public sector and/or government decision-makers, on the one hand, and of non-governmental health services actors in civil society and private life, on the other. In tax-funded European health systems up to the 1980s, the state and other public sector decision-makers played a dominant role over health service provision, typically operating hospitals through national or regional governments on a command-and-control basis. In a number of countries, however, this state role has started to change, with governments first stepping out of direct service provision and now de facto pushed to focus more on steering provider organizations rather than on direct public management. In this new approach to provider governance, the state has pulled back into a regulatory role that introduces market-like incentives and management structures, which then apply to both public and private sector providers alike. This article examines some of the main operational complexities in implementing this new governance reality/strategy, specifically from a service provision (as opposed to mostly a financing or even regulatory) perspective. After briefly reviewing some of the key theoretical dilemmas, the paper presents two case studies where this new approach was put into practice: primary care in Sweden and hospitals in Spain. The article concludes that good governance today needs to reflect practical operational realities if it is to have the desired effect on health sector reform outcom

Challenges facing the United States of America in implementing universal coverage

In 2010, immediately before the United States of America (USA) implemented key features of the Affordable Care Act (ACA), 18% of its residents younger than 65 years lacked health insurance. In the USA, gaps in health coverage and unhealthy lifestyles contribute to outcomes that often compare unfavourably with those observed in other high-income countries. By March 2014, the ACA had substantially changed health coverage in the USA but most of its main features - health insurance exchanges, Medicaid expansion, development of accountable care organizations and further oversight of insurance companies - remain works in progress. The ACA did not introduce the stringent spending controls found in many European health systems. It also explicitly prohibits the creation of institutes - for the assessment of the cost-effectiveness of pharmaceuticals, health services and technologies - comparable to the National Institute for Health and Care Excellence in the United Kingdom of Great Britain and Northern Ireland, the Haute Autorite de Sante in France or the Pharmaceutical Benefits Advisory Committee in Australia. The ACA was - and remains - weakened by a lack of cross-party political consensus. The ACA\u27s performance and its resulting acceptability to the general public will be critical to the Act\u27s future