A Socio-instutionalist Critique of the 1990s' Reforms of the United Kingdom's National Health Service

This paper argues that the on-going reforms to the UK's National Health Service initiated in the 1990s represent potentially profound institutional change to the values underpinning the process of care. The market-orientation of the reforms is highlighted, and it is asserted that the theoretical rationale for this is informed by the nascent neoclassical health economics and new institutionalist literatures, which exhibit utilitarian propensities in that both stress outcomes and at best relegate process. Drawing from the seminal contribution of Thorstein Veblen, the paper argues that market-oriented reform in the UK may induce a shift from a Hippocratic ethos to a more individualistic value system.     

经济学家、经济学与中国改革

本文回顾了中国经济学家伴随中国改革成长的历程 ,历数诸多为中国建立现代市场经济制度 ,进行过艰苦的理论和思想探索的经济学家 ;并通过具体实例说明经济学家通过对于现代经济科学认识的深化 ,在改革的重大关头和事件上所发挥的重要作用。中国改革的深入 ,对于经济科学的要求愈来愈高 ,经济学的新课题层出不穷。因此 ,本文提出亟需加快我国经济科学学科建设的若干建议。     

Gustav Schmoller's Historico-Ethical Political Economy : ethics,politics and economics in the younger German Historical School, 1860-1917

Gustav Schmoller, the head of the younger Historical School of political economy in Imperial Germany, was characterized as the man who had brought about the ‘decisive turn’ towards Sozialpolitik and had given it a scientific basis. His holistic understanding of political economy became a tradition among German administrative bureaucracy. His economic doctorine must have been seen in the context of a comprehensive social theory linking an idealist statism with an ethical evolutionism against the background of an historicist world view. The paper critically discusses how Schmoller wanted to force these competing streams of thought and their influences among his contemporaries into a developmental model that would harmonize the radical social changes of his day.     

Health and economic impact of PHiD-CV in Canada and the UK: a Markov modelling exercise

Abstract

Objective:

The spectrum of diseases caused by Streptococcus pneumoniae and non-typeable Haemophilus influenzae (NTHi) represents a large burden on healthcare systems around the world. Meningitis, bacteraemia, community-acquired pneumonia (CAP), and acute otitis media (AOM) are vaccine-preventable infectious diseases that can have severe consequences. The health economic model presented here is intended to estimate the clinical and economic impact of vaccinating birth cohorts in Canada and the UK with the 10-valent, pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) compared with the newly licensed 13-valent pneumococcal conjugate vaccine (PCV-13).

Methods:

The model described herein is a Markov cohort model built to simulate the epidemiological burden of pneumococcal- and NTHi-related diseases within birth cohorts in the UK and Canada. Base-case assumptions include estimates of vaccine efficacy and NTHi infection rates that are based on published literature.

Results:

The model predicts that the two vaccines will provide a broadly similar impact on all-cause invasive disease and CAP under base-case assumptions. However, PHiD-CV is expected to provide a substantially greater reduction in AOM compared with PCV-13, offering additional savings of Canadian $9.0 million and £4.9 million in discounted direct medical costs in Canada and the UK, respectively.

Limitations:

The main limitations of the study are the difficulties in modelling indirect vaccine effects (herd effect and serotype replacement), the absence of PHiD-CV- and PCV-13-specific efficacy data and a lack of comprehensive NTHi surveillance data. Additional limitations relate to the fact that the transmission dynamics of pneumococcal serotypes have not been modelled, nor has antibiotic resistance been accounted for in this paper.

Conclusion:

This cost-effectiveness analysis suggests that, in Canada and the UK, PHiD-CV’s potential to protect against NTHi infections could provide a greater impact on overall disease burden than the additional serotypes contained in PCV-13.     

中国农村的收入差距与健康

随着收入差距的扩大,收入分配对健康和健康不平等的影响日益受到关注。本文利用中国健康营养调查(CHNS)1997年和2000年农村的面板数据回答两个问题:收入差距对健康的影响以及影响健康的方式;收入差距的扩大是否会导致健康不平等的加剧,尤其是低收入人群的健康是否受到更为不利的影响。研究发现,首先收入差距对健康的影响存在滞后效应;其次,收入差距对健康的影响呈现“倒U”型,在收入差距较高时,收入差距对健康的影响主要为负向的,一个可能的原因是收入差距影响到公共卫生设施的供给。再次,收入差距的扩大会加强收入效应,其含义是如果低收入人群的收入更容易受到负向冲击,那么收入差距对低收入人群的健康更为不利。     

中国老人医疗保障与医疗服务需求的实证分析

本文采用2005年中国老年健康长寿调查数据库(CLHLS)22省调查数据,建立了中国65岁以上老年人群的医疗服务需求模型,实证分析了医疗保障对老人医疗服务需求的影响。本文的主要结果如下:第一,医保制度对老人医疗服务的影响主要表现在提高就医程度,而非就医选择行为的改变,同时医保制度又明显地促进了老人及时就医率。第二,医保制度对减轻老人家庭医疗负担具有显著作用。第三,城镇医保和公费医疗所发挥的作用明显高于其他保险形式。本文的基本判断是,国家医保政策在改善中国老人医疗服务利用和减轻老人家庭医疗负担方面确实发挥了良好的积极作用,并且更多惠及了就医必要性更大的老年人群,从资源配置角度看是提高效率的。因此,进一步推进全民基本医疗保障制度的建设不仅是国家惠及全民的医改重任,也是中国医疗卫生应对老龄化挑战的有效选择。     

开放视角下的国家综合负债风险与市场化分担

随着中国经济金融的日益开放,中国国家综合负债的规模与结构在动态变化:一方面,国家综合负债的某些旧因素(如银行不良资产)的存在形式发生了变化,另一方面,国家综合负债的一些新因素(社保基金缺口、巴塞尔协议的顺周期影响和汇率波动导致的外汇资产损失)开始显现。从开放视角考察,中国的国家综合负债风险形势仍较为严峻。在政府承担社会性支出的基础上,更多地重视和运用市场化分担方式是化解和防范国家综合负债风险的基本途径,保持经济持续稳定增长是应对国家综合负债风险的根本保障。     

社会保障制度改革的路径选择——由美国社会保障“私有化”争论引发的思考

边际改革与结构性改革是社会保障领域中两类重要的改革方式.本文以美国社会保障"私有化"争论为例,通过分析这场争论的缘由与实质,以及社会保障制度边际改革和结构性改革的作用机理,指出社会保障制度改革的路径选择是多支柱模式的结构性改革方式,这是主流趋势;边际改革与结构性改革不是非此即彼关系,而是互补关系.     

The Dynamics of the Dutch Health Care System--A Discourse Analysis

In this article, we analyze recent dynamics of the Dutch health care sector, a hybrid system of public, private and professional elements, in terms of clashing discourses. Although these elements are intricately interwoven, this does not mean that the system is stable. Most notably, since the eighties the introduction of more market elements in the health care system has been widely debated. Hospitals introduced different methods commonly used in businesses, for instance. The position of managers in the institutions of health care has become more central. A discourse analysis shows the concomitant patterns of institutional change in the health care sector. We distinguish four different discourses concerning health care: economic, political, medical-professional and caring discourses. These different discourses give rise to, for example, different views of good care, the character and position of the patient, and leadership in health care organizations--views that sometimes clash intensely.     

科技体制转轨应遵循的规律及其配套改革模型

本文说明了科技体制转轨过程中应遵循的规律,即要素围绕优势创新集体优化重组,以新机制运行增量并渐进地带动存量调整,引导并调动主体积极性,中年科技人员有序流动,科技活动的定向研究和自由探索相结合的规律;分析了我国科技资源配置和利用方面存在的不足,科技体制改革方式中值得改进之处,并提出了科技体制转轨的诱致性配套改革模型。本文的探索,对于认识科技体制转轨的规律性,改进对科技体制改革的领导,都可能具有一定的理论意义和实践意义。     

养老模式对健康的影响

中国人口老龄化趋势日益明显,这给养老、医疗、社会服务带来了巨大的压力。本文从居住模式和主要经济来源两个方面来界定中国老年人的养老模式,利用经济学方法,根据2002年、2005年中国老年人口健康状况调查数据(Chinese Longitudinal Healthy Longevity Survey,CLHLS),从实证角度,讨论了中国不同养老模式如何影响老年人的健康状况,并且分析了这一关系是否存在性别差异、城乡差异和年龄段差异。研究发现,养老模式是关系到中国老年人健康的一个关键因素,经济与居住均独立的老年夫妻有最明显的健康优势和主观幸福度优势,而依靠子女供养或政府补助的个人独居养老模式是最差的。这些经验发现可以为政府改善老龄人群的健康提供可靠的政策依据。     

Social Security Reform and National Wealth

Recent trends in common stock prices suggest a distinction between increases in national net worth and flows of physical investment. In this paper we present a simple overlapping generations model in which such differences can arise: technological progress occurs exogenously, yet firms own new technologies for a time. We examine possible consequences for social security reform. Reform which increases private saving depletes part of its force raising the (capitalized) price of proprietary technologies. A calibrated example suggests an increase in physical capital one-third smaller than without inelastic factors. Both steady states and transition paths are considered.     

医疗卫生基本公共服务的城乡差距及均等化路径

当前,我国城乡之间的医疗卫生服务不均等已成为一个重要的社会问题。本文通过医疗卫生费用和医疗卫生资源的城乡数据分析得出城乡之间的医疗卫生公共服务差距巨大,并通过2000—2008年城乡医疗保健费用的泰尔指数分析,发现城乡组间对城乡医疗卫生公共服务差距的贡献基本上在80%以上,几乎是组内差距贡献的4倍,而从两组的内部差距来看,农村内部的不均等程度要稍高于城市内部的不均等程度,根据分析结果并从财政向农村医疗卫生的投入倾斜、城乡医疗保险制度的整合、医疗体制的深化改革等方面就如何促进医疗卫生公共服务城乡均等化进行探讨。     

美国医疗保健模式及其改革

由于倡导自由市场经济的文化和社会背景,美国是唯一没有实行全国统一的医疗保障制度的发达国家。本文对美国医疗保险制度、美国医院的管理运行机制、美国医疗保险付费方式的沿革进行了系统的介绍,并梳理了美国医疗保健管理模式的特点与问题,结合奥巴马政府医疗保健改革要点,对我国医疗保健体系改革提出了几点建议。     

Health,Social Insurance and Income

Health, a form of human capital, can be defined by longevity and physical wellbeing. Social policy decisions require an understanding of the factors that contribute to the creation of health inequalities. To learn more about socioeconomic variables and health capital, this paper examines the relationship between three key variables: health, social insurance, and income, for the Swedish population. Using a randomized research survey design, data from 3,600 participants of a larger Swedish study, conducted in 2005, was analyzed. A linear model of Three Stage Least Squares was chosen to correct for simultaneous bias in the Health, Social Insurance, and Income (HSI) Model. Findings confirm the importance of socioeconomic, behavioral and environmental factors in explaining health inequalities. The results clearly show men, educated people, nonsmokers, individuals that exercise and youngsters possess higher health status than other people. The dependency on social insurance is mainly caused by poor health; a higher degree of social insurance dependency was offset by income increases due to age and higher professional level.      

台湾地区全民健保制度实施绩效论析

全民健保制度是台湾地区第一个涵盖岛内全体民众的社会保险制度。自实施以来,全民健保已经取得较好的绩效,表现在岛内民众就医公平性和可及性大大提高、民众满意度较高、医疗保健总支出成长趋于稳定。全民健保制度不仅使岛内民众得到实惠,而且其成功的经验引起了国际健康保险界的关注。     

Unemployment and the economics of gradualist policy reform

This paper investigates the efficiency of adjustment to economic reform programs when the cost of adjustment arises from high unemployment that can be generated as contracting sectors shrink faster than expanding sectors grow. Under plausible assumptions on the adjustment process, the speed of adjustment to “shock therapy” reforms is shown to be excessively rapid, and the rate of unemployment to be excessively high during the transition to the new equilibrium. The authorities can improve the efficiency of the adjustment by removing the distortion gradually, rather than abruptly. Gradualism has beneficial income distributional, as well as efficiency properties, because it improves welfare of the unemployed, who are necessarily the least advantaged social group in this model.     

The problem of the uninsured

The problem of the uninsured cannot be fully understood without considering the role of non-market alternatives to ‘market insurance’ called ‘self-insurance’ and ‘self-protection’ (SISP), including the public ‘health care safety-net’ system. We tackle the problem by formulating a ‘full-insurance’ paradigm that accounts for all four interacting insurance measures. We apply two versions of the full-insurance model to estimate, via calibrated simulations, the impacts of SISP on the fraction of uninsured, health spending, and health levels, and to assess how the mandated Affordable Care Act might affect these outcomes in comparison with the CBO projections in 2010. The results indicate that policy analyses which overlook the role of the real price of market insurance relative to the shadow prices of SISP in determining the decision to insure can grossly distort the capacity of mandated reforms like the ACA to insure the uninsured, contain overall health care costs, and improve health and welfare outcomes.     

Culture and the Labor Market

This paper explores the relationship between culture and labor market behavior. An attempt is made to clarify, from an economic perspective, the meaning of culture; to discuss the importance of cultural studies in the economic analysis of the labor market; and to outline the major theoretical issues that are associated with adopting a cultural perspective on economic behavior in the labor market.     

Academic Medicine Under Economic Stress: A Case Study of the Institutional Change Transforming American Health Care

American Academic medicine--the system of education and research that trains the coming generations of physicians, produces new basic and clinical bio-medical research and provides the medical safety net in many U.S. urban areas--is in a funding crisis. This essay lays out an historical and analytical account of the institutions, functions and funding mechanisms of this enterprise. The objective is to interpret the forces that led to the current impasse in which the medical education establishment now finds itself, and what the future is likely to hold as the forces of budgetary stringency and market competition continue to accelerate. A comprehensive review of the cross-subsidy system, its intricate relationship to the federal financing of health care and its origin in the Vannevar-Bush-inspired post-war research establishment is offered. The standpoint of economic theory is then taken to suggest that the intertwined functions of academic medicine be viewed from two perspectives. One, it can be viewed as a financially unnecessary mix of public and private goods. Two, it is an institutional framework for joint production that evolved under the post-Flexner, post-Bush era reforms of scientific medicine, but which now may be in need of modifications to its mission.