Has this doctor-governor found the key to health reform?. Interview by Berkeley Rice

Under the leadership of internist Howard Dean, the nation's only physician-governor, Vermont is adopting a comprehensive health-care plan that will revolutionize the way the state's doctors practice medicine. As Vermont goes, so may the nation, for Dean is one of the key advisers to the Clinton administration on health-care reform. But if the Vermont plan serves as a model for the rest of the country, many doctors may find it a better pill to swallow. Among other things, it could mean that nearly all the state's physicians will, in effect, participate in a state-run HMO and be subject to global fees and budgets that will also cover hospitals (see opposite page). While the plan's specific provisions are still being debated, Dean's views have spread to other states and to the Clinton administration through his role as co-chairman of the National Governor's Association task force on health care. In a recent interview with Senior Associate Editor Berkeley Rice in the governor's office in Montpelier, Dean discussed Vermont's new health plan, its importance as a model for other states, and his unique perspective as physician-governor.     

欧盟《患者跨境医疗权利指令》实施及其借鉴

提升欧盟成员国卫生体系的协同效应,解决共同面临的健康挑战,是欧盟卫生体系一体化发展的重要目标。2013年10月,欧盟所有成员国通过了《患者跨境医疗权利指令》的法律,并在全欧盟范围内正式生效并实施。该指令针对患者的权利做了一些调整,扩大了医疗服务范围,提出了报销原则、成员国职责和创新性措施,如,建立国家联系点,改善各国电子医疗系统,促进各国卫生技术评估,促进各国医疗产品使用和处方的互认,以及促进开发和建立欧洲参考网络等。该指令旨在通过促进成员国合作组织和提供医疗服务,为欧盟公民提供安全、高质的跨境医疗服务。中国与欧盟社会管理体系虽然不同,但该法令在立法过程、实施原则和具体措施等方面,对我国正在实施的医药卫生体制改革有所借鉴。     

ENTREPRENEURSHIP AND JOB LOCK: THE INTERACTION BETWEEN TAX SUBSIDIES AND HEALTH INSURANCE REGULATIONS

This paper demonstrates that health insurance tax subsidies increase self‐employment, but that the effect differs substantially based on nongroup market regulations and health status. Using the Panel Study of Income Dynamics, I show that households that cannot purchase health insurance because of a preexisting condition do not respond to tax subsidies in states in which they would be denied insurance, but they respond strongly in states in which they face risk‐rated premiums. Households respond similarly to tax subsidies in states with nongroup market regulations similar to those established by the Affordable Care Act, regardless of preexisting conditions. (JEL H20, I13, J30)     

Reprint of: Sewage Pollution and Institutional and Technological Change in the United States, 1830-1915

This article examines institutions for water pollution control and their interaction with water supply and sanitation technologies in the United States before the First World War. The article discusses how growth of settlements polluted waters and created pressure to adopt local institutional responses and networked water supply and sewerage technologies in the mid-19th century. However, the new urban technologies undermined local institutional responses and expanded the scale of water pollution problems they were expected to resolve. Water companies, households and local governments litigated their water pollution conflicts in the courts in the absence of other alternatives. In the end of the 19th century, many states adopted water pollution policies. At first, public health authorities enforced the new policies to protect public water supplies from sewage contamination. However, when the effectiveness of filtration and chlorination of drinking water was demonstrated in the early 20th century, public health authorities ceased to enforce discharge prohibitions and instead pressured water companies to adopt the new technological measures to protect public health.     

Sewage pollution and institutional and technological change in the United States, 1830–1915

This article examines institutions for water pollution control and their interaction with water supply and sanitation technologies in the United States before the First World War. The article discusses how growth of settlements polluted waters and created pressure to adopt local institutional responses and networked water supply and sewerage technologies in the mid-19th century. However, the new urban technologies undermined local institutional responses and expanded the scale of water pollution problems they were expected to resolve. Water companies, households and local governments litigated their water pollution conflicts in the courts in the absence of other alternatives. In the end of the 19th century, many states adopted water pollution policies. At first, public health authorities enforced the new policies to protect public water supplies from sewage contamination. However, when the effectiveness of filtration and chlorination of drinking water was demonstrated in the early 20th century, public health authorities ceased to enforce discharge prohibitions and instead pressured water companies to adopt the new technological measures to protect public health.     

Health insurance: Medical treatment vs disability payment

We present arguments for treating health insurance and disability insurance in an integrated manner in economic analysis, based on a model where each individual’s utility depends on both consumption and health and her income depends on her earning ability. When purchasing insurance, she may choose a contract that offers less than full medical treatment. We find that high-ability individuals demand full recovery and equalize utility across states, while low-ability individuals demand partial treatment and cash compensation and suffer a loss in utility if ill. Our results carry over to the case where health states are not observable.     

Health Expenses: Evidence from the Club Clustering Approach

This paper explores convergence of real health expenses across the Indian states. The new panel convergence methodology developed by Phillips and Sul (Econometrica 75:1771–1855, 2007) is employed. The empirical findings suggest that these states form distinct convergent clubs, exhibiting considerable heterogeneity in the underlying health expenses patterns.     

Borders and Governance: An Analysis of Health Regulation and the Agri-food Trade

The contemporary dynamics of states, borders, and markets suggest the need for non-traditional methods of regulation and international cooperation in areas such as border inspections and management. The emerging literature on cross-border regions and multi-level governance suggests a framework to understand this development within the general transformation of states under globalisation. To explore these ideas, in this article we focus on the arena of health regulation and the international agricultural and food trade. Multilateral bodies such as the World Trade Organization (WTO), the World Organization for Animal Health (OIE), and the International Plant Protection Convention (IPPC) have endorsed the policy concept of “regionalisation” as a means by which states can preserve trade relations when sanitary (human or animal health) or phytosanitary (plant health) hazards threaten a country's trading status. In this paper, two cases – one historical and one contemporary – illustrate that regionalisation offers a largely functional application of multi-level governance to enhance regulatory and trade capacity. We conclude that governance changes indicated by regionalisation may provide further evidence for the transformation of borders, regions, and states in an era of globalisation.     

Spatial and economic patterns in life expectancy among US States

This study investigates the determinants of gender-specific life expectancy across US states over the period 1995–2007. We employ a production function specification where life expectancy depends on health expenditure, income, education and lifestyle variables, allowing for spatial effects. Empirical results suggest that education attainment and health expenditure are the main factors behind improving longevity, whereas smoking bears a strong negative influence. For robustness purposes, we also use health spending as well as education criteria, apart from geographical ones to model interstate spillovers. In the former case, states with similar health expenditure are ‘neighbors’ and affect positively the life expectancy process. If education is applied instead of health spending together with geographic proximity, the spatial correlation is insignificant, i.e. education ‘neighbors’ do not affect life expectancy. Our findings do not imply significant gender differences regarding health production. The results suggest that health care policy will have to focus on wider economic and social considerations, like education and lifestyle changes, except medical care provision in order to exploit the full potential for life expectancy improvements of the US population.     

Variation in Health Expenditures: Is It Just Income or other Factors? Empirical Investigation Using a Panel of Indian States

The primary query of this paper centres on the role played by income in determining the extent of fund allocated by Indian states for improvement of health of its population. Drawing data from the fourteen major states of India over a time span of twenty-three financial years (1974–75 to 1996–97) and using recent advances in panel data time series econometrics, this paper documents the presence of a long run relationship between income and health expenditure. The long-run elasticity estimates reiterate that publicly provided health services should be considered as “necessities”. Results the panel error correction model demonstrate that ageing of the population and proportion of rural population are the only non-income factors, which exert a significant positive impact on real per capita health expenditure. This is particularly important given the demographic transition that India is passing through.

     

Regulation and the optimal size and type of abortion provider

This paper examines the changes in the size distribution of firms in the abortion services market between 1978 and 1992 in the US. The results indicate that for the entire 15-year period, the market shares of large abortion providers were increasing in both restrictive and nonrestrictive states. Also clinics and physician offices appear to be gaining market share relative to hospitals. These increasing market shares could be due to many factors, such as changes in the technology of providing abortions on an outpatient basis and changes in the relative prices of abortions in hospitals and abortions in non-hospital settings. Furthermore, this paper includes an analysis of the impact of state-level Medicaid funding regulations on the number, size, and type of abortion provider. These results have important implications for women's access to abortion services and for infant and maternal health.     

Economic burden of amyotrophic lateral sclerosis in the United Kingdom

Abstract

To assess the economic burden of amyotrophic lateral sclerosis (ALS) in the United Kingdom, yearly direct medical costs were determined for four defined ALS health states (mild, moderate, severe and terminal disease stages). Resource utilisation patterns for each health state were obtained from United Kingdom neurologists and local costs (1996/97) were attached to the resources. The annual direct cost of the health states increased from £1185.20 in mild disease to £3127.51 in the terminal state. Hospitalisation was a major contributor to total cost in mild (43.3%), severe (31.6%) and terminal (45.1%) states. In contrast, in moderate disease the impact of hospitalisation was minimal (0.8%) compared to physician remuneration costs (59%). The economic burden of ALS is therefore directly related to the severity of the disease. The study identifies the major cost drivers in current ALS care and provides a means for determining how potential therapeutic interventions might affect the overall cost of the disease.     

On preferences with infinitely many subjective states

Models with subjective state spaces have been extremely useful in capturing novel psychological phenomena that consist of both a preference for flexibility and for commitment. Interpreting the utility representations of preferences as capturing these phenomena requires one to use the notion of a sign of a state. For linear preferences, we completely characterise the sign of a state in terms of its analytic representation as an integral with respect to a signed measure. In models with finitely many states, a state is either positive or negative, but never both. We show that in models with infinitely many states, a state can be both positive and negative. Thus, models with finitely many states may not capture all the behavioural features of an infinite model. Our methods are also useful in constructing utility functionals over menus with desired local properties.     

The Use of Dental Services among Older Australians: Does Location Matter?

Based on the National Health Survey of 2005, this study examined the use of dental services among non‐institutionalised older Australians. The results of the regression revealed differences in the frequency of dental visits across the states. The greater the public dental health expenditure per capita in each state the more likely residents of that state were to have visited the dentist in the previous year. Older people residing outside major cities experienced the greatest disadvantage. In addition to the socioeconomic factors reported by studies, in Australia inequalities in access to dental health services was associated with urbanicity and Australian states.     

Seeking the cure

With Washington paralyzed by partisan politics, states are taking the lead in experimenting with ways to solve the nation's growing health care crisis. This is the second of two articles on responses to the growing health care crisis. A report on organized labor's efforts begins on p. 704.     

The Organization of Public Service Provision

This paper addresses the question of how the responsibility for the delivery of social services, including health, education, and welfare programs, should be divided between state and central governments. We combine a random voting model and the incomplete contracts paradigm to formalize the trade‐off between central and state responsibility for service delivery, and find that authority should rest with the party for whom the marginal impact of the service on re‐election chances is greater. This in turn means that, other things equal, states with lower than average health, education, or welfare status should be given responsibility for service delivery, while authority in states with above average indicators should reside with the central government. Also, we show that there is no presumption that states that are given authority for service delivery should necessarily be granted expanded tax authority.     

我国大型零售商多业态扩张模式研究

在国际零售巨头纷纷涌入我国大中小城市、零售市场竞争日益激烈的背景下,收取通道费成为大型零售商盛行的盈利模式。但连续多年位居全国连锁10强的华润苏果超市却形成了自己独特的盈利模式——多业态扩张模式。本文将分析华润苏果的蜂窝式多业态密集布点、直营与特许加盟双轮驱动的渗透式扩张,以期对我国零售商的发展有所启迪。     

Fishing in a Shallow Lake: Exploring a Classic Fishery Model in a Habitat with Shallow Lake Dynamics

Renewable resources such as fish exist within habitats. Harvesting activities may directly impact the habitat, beyond the influence caused by changing the balance between species. When harvesting activities impact stock size and habitat health in different ways, both states must be explicitly considered. A classic fisheries model is embedded in a habitat that exhibits shallow lake dynamics, where carrying capacity depends on habitat health and fishing effort damages the habitat. Hysteresis in the habitat dynamics can manifest itself as multiple steady states for both the dynamic and open access solutions. Numerical explorations of the model suggest that a new fishery in such a setting should often be managed to protect the health of the habitat, while it may not be optimal to restore a fishery in an already degraded habitat. Conventional policy tools applied in their classic form are unlikely to be effective.     

New evidence on factors affecting the level and growth of US health care spending

The dual problems of high and rising medical care expenditures and substantial differences in spending across geographic regions have long plagued the US health care system. We provide new evidence to explain why some states and regions of the country spend much more on medical care than others, and why health care spending for the nation as a whole has been growing rapidly over the last several decades. To do this, we estimate a health care spending panel data model using annual data on all 50 states for the period 1993–2009. Our model includes a number of socio-economic, health care provider, lifestyle and environmental variables that past studies indicate may affect the level or growth of aggregate health care spending. We exploit the time effect component of our model to obtain an upper-bound estimate of the effect of advances in medical technology. Our findings indicate that the most important factors influencing the level of spending are availability of providers, income, excessive alcohol consumption, Medicaid coverage, HMO health plans and the proportion of the population elderly and African-American. The principal drivers of growth have been the continual introduction of new medical technologies, and the growth of providers and income.