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Abstract:
The dialogue links a portrait of health reform politics in the US from the seventies to 2008 by Ted Marmor with a comparable, parallel essay by Antonia Maioni about Canada's struggles. The pairing is also unusual in having the North Americans comment on each other's portrayal. They do not disagree so much with the descriptions as with how those facts appear and what they mean when looking comparatively.

Politics, Health Reform, Comparative Policy Analysis

Abstract:
No one misses the onslaught of claims about reforming modern medical care. How doctors should be paid, how hospitals should be paid or governed, how much patients should pay when sick in co-payments, how the quality of care could be improved, and how governments and other buyers could better control the costs of care - all find expression in the explosion of medical care conference proceedings, op-eds, news bulletins, journal articles, and books.

This collection of articles takes up a key set of what the author regards as particularly misleading fads and fashions - developments that produce a startling degree of foolishness in contemporary discussions of how to organize, deliver, finance, pay for and regulate medical care services in modern industrial democracies. The policy fads addressed include the celebration of explicit rationing as a major cost control instrument, the belief in a "basic package" of health insurance benefits to constrain costs, the faith that contemporary cross-national research can deliver a large number of transferable models, and the notion that broadening the definition of what is meant by health will constitute some sort of useful advance in practice.

Healthcare, Fads, Fallacies, Aging, Medical Care Budgets

Abstract:
Canada and the United States are typically regarded as 'laggards' in welfare state development. They are regularly classified together as 'liberal' welfare states, with relatively lower levels of welfare state fiscal effort and coverage. There is some truth to this portrait overall, but in comparison to one another and in terms of specific social policies, it is the differences that stand out. These differences are evident in a number of important respects: the structure and distribution of health care and pension benefits; the levels of effort to assist particular groups; and, as well, the timing and coverage of specific programs.

Abstract:
The main point of this article is to explore the methodological questions raised by weaknesses in international comparative work in the field of health policy. The core question is how competent learning from one nation to another can take place. The article argues that there is a considerable gap between the promise and the actual performance of comparative policy studies. Misdescription and superficiality are all too common. unwarranted inferences, rhetorical distortion, and caricatures - all show up too regularly in comparative health policy scholarship and debates.

The article first describes the context of the health and welfare state reform debates during the past three decades. In almost all industrialized democracies, rising medical expenditures exacerbated fiscal concerns about the affordability of the mature welfare states. In reaction to pressure for policy change in health care, policy makers looked abroad for promising solutions of domestic problems. The following section takes up the topic of cross-national policy leaning. Then, it critically reviews recent debates about health care reforms and addresses the purposes, promises and pitfalls of comparative study in health policy. The next section categorizes existing comparative health policy literature to highlight the character, possibilities and limits of such work. The concluding section returns to the basic theme: the real promise of comparative scholarship and the quite mixed performance to date.

Abstract:
This article seeks to clarify the contemporary Medicare debate by providing, first, an historical perspective on Medicare's origin and development and, second, an understanding of the analytical damage done by an all-too-common style of Medicare policy analysis.

We have two central claims. First, we argue that the contemporary debate over Medicare reflects the program's distinctive political development, its generally low salience among the public, and the partisan rhetoric of politicians engaged in broader ideological battles. Emerging more of a political than a programmatic logic, Medicare's guiding social insurance philosophy was never fully articulated to the broader public. Moreover, its social insurance rationale has eroded over time, in part through piecemeal changes to the program. The public seems to have embraced Medicare with only a modest understanding of its functional form and remains largely ignorant of the program's real status or likely future. Moreover, the typically remote position Medicare occupies in public discourse feeds into the recurring atmosphere of crisis so easily stoked and exploited by partisans hoping to frame debate over Medicare to their ideological and electoral advantage.

Our second point is that the debate's confusions have been magnified by the lack of rigor with which many policy analysts have characterized the political context of Medicare reform. Because many policy analysts pay only cursory attention to the political analysis of Medicare's origins and recent developments, the fundamental issues at stake in the debate over Medicare's future are regularly obscured.

Abstract:
The premise of this article is that the concept "managed care," like many concepts now prominent in commentary about medical care finance and delivery, is incoherent and thus a barrier to useful analysis. "Managed care," we argue, is a confused assemblage of market sloganeering, aspirational rhetoric, and business school jargon. It presupposes answers to central questions about changes in modern medicine rather than helping to address those questions. To demonstrate this, we first discuss the 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 such an 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 or projected developments in methods of reimbursement and techniques of management.

Abstract:
Many health policy analysts argue that demographic pressures, the inflationary nature of fee-for-service payment, and the uncontrollable nature of defined-benefit insurance make Medicare unsustainable in its current form. They assert that Medicare can remain fiscally viable in the next century only by embracing a voucher system and exposing beneficiaries to the economic consequences of their medical care decisions. We argue here, however that Medicare need not rely on vouchers or on placing financial incentives on individual beneficiaries to control costs. Instead, we contend that Medicare can control expenditures the way most other industrial democracies do: through budgetary caps and centralized regulation of provider payments.

Abstract:
The premise of this article is that the category "managed care", like many concepts now prominent in commentary about medical care, poses a barrier to credible analysis. A confused assemblage of market sloganeering, aspirational rhetoric, and business school jargon, the term "managed care" presupposes answers to central questions about contemporary health insurance and its evolution rather than helping to address those questions. The article first discusses the context in which managed care claims have arisen and outlines the diverse trends to which the category is regularly applied. We then suggest an alternative approach to characterizing these trends that breaks them down into their constituent elements -- managerial, financial, and organizational. Our core argument is that health policy research requires more neutral categories for making sense of past and projected developments in methods of reimbursement, techniques of management, organizational forms, and the distribution of risk.

Abstract:
This article is a form of thinking about the future properly regarded as conditional forecasting. It begins by reminding readers of the enormous changes in American medicine since World War II. The second part revisits critically an earlier effort at conditional forecasting for 1995 that Paul Starr and I published in the early 1980s. Besides reviewing the prescience of our forecasts, the second part outlines the earlier trends in progress we identified and the four combinations of political and economic settings we explored. On that basis, the final part takes up the challenge of anticipating sensibly some possible medical futures in the America of the early twenty-first century, a task which excludes simple extrapolation.

Abstract:
The scope of this essay is broad -- the dangers that much conventional management commentary represents for medical institutions and those who work in them. It emphasizes two themes in management talk about healthcare.

The first is the character of the language used to describe health care arrangements -- the "rhetoric of medical managerialism," a rhetoric that powerfully and misleadingly combines the jargon of modern management schools with the marketing hype of advertising. Second, it includes some observations about what this cautionary tale might mean for the daily work of health care professionals.

Abstract:
The Oregon Health Plan (OHP) has been widely heralded as an important innovation in medical care policy. Oregon's pioneering model of prioritizing funding through systematically ranking
services drew an extraordinary amount of national and international attention. Indeed, the Oregon story has seemed so compelling and by now is so familiar that it has attained what Rudolf Klein termed "nearly mythical status" in the health policy community.

The article proceeds in three sections. First, we very briefly review the original proposals and ensuing (and misleading) debate over rationing in Oregon. Next, we explore how the politics of rationing unfolded in Oregon from the enactment of OHP to its implementation. Finally, we consider the character of Oregon's innovation and the broader lessons that it holds for reform efforts elsewhere.