"A marvelous collection of ideas and insights by first-rate scholars. This book lays a foundation for more creative and effective policy-making." - Stephen M. Shortell, Dean and Blue Cross of California Professor of Health Policy and Management, University of California, Berkeley

Health care delivery in the United States is an enormously complex enterprise, and its $1.6 trillion annual expenditures involve a host of competing interests. While arguably the nation offers among the most technologically advanced medical care in the world, the American system consistently under performs relative to its resources. Gaps in financing and service delivery pose major barriers to improving health, reducing disparities, achieving universal insurance coverage, enhancing quality, controlling costs, and meeting the needs of patients and families.

Bringing together twenty-five of the nation's leading experts in health care policy and public health, this book provides a much-needed perspective on how our health care system evolved, why we face the challenges that we do, and why reform is so difficult to achieve. The essays tackle tough issues including: socioeconomic disadvantage, tobacco, obesity, gun violence, insurance gaps, the rationing of services, the power of special interests, medical errors, and the nursing shortage.

Linking the nation's health problems to larger political, cultural, and philosophical contexts, Policy Challenges in Modern Health Care offers a compelling look at where we stand and where we need to be headed.

The 2006 book, supported by a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research, traces the evolution of celebrities and their relationship with the public and the media around disclosure of serious illness. Here, Lerner examines the impact celebrities have had on Americans’ personal struggles with illness, and how those stories have helped shape health care policy. What he sees is a cultural shift—taking what were once considered very private matters and making them stories of great public interest.

"This is a stunning book -- comprehensive and perceptive. Searching Eyes: Privacy, the State, and Disease Surveillance in America is a major achievement in interdisciplinary scholarship and historical interpretation, and will remain the definitive work on this important subject for many years to come."--Theodore M. Brown, Ph.D., Professor of History, Community and Preventive Medicine, and Medical Humanities, University of Rochester.

"Brown's book presents new analytic arguments and sound suggestions for what works in community-based environmental health movements and what does not." -- Kelly Moore, University of Cincinatti

Book Description

The alarming increase in the incidence of environmentally induced diseases has led many scientists and environmental health advocates to challenge prevailing epidemiological paradigms. Focusing specifically on "contested illnesses" whose origins have generated intense debate in the medical and political communities-breast cancer, asthma, and Gulf War-related health conditions-Phil Brown shows how the debate has prompted scientists and concerned citizens to launch an environmental health movement that has revolutionized scientific thinking and policy. Brown argues that organized social movements are crucial in recognizing and acting to combat environmental diseases. His probing look at dominant biomedical models, the ways scientific findings are made available to the public, and the changing nature of policy offers a new perspective on health and the environment and the relationship between people, knowledge, power, and authority.

Paying the Tab, the first comprehensive analysis of this complex policy issue, calls for broadening our approach to curbing destructive drinking. Over the last few decades, efforts to reduce the societal costs--curbing youth drinking and cracking down on drunk driving--have been somewhat effective, but woefully incomplete. In fact, American policymakers have ignored the influence of the supply side of the equation. Beer and liquor are far cheaper and more readily available today than in the 1950s and 1960s.

Formal concern with diversity in American medical research, Epstein shows, is a fairly recent phenomenon. Until the mid-1980s, few paid close attention to who was included in research subject pools. Not uncommonly, scientists studied groups of mostly white, middle-aged men—and assumed that conclusions drawn from studying them would apply to the rest of the population. But struggles involving advocacy groups, experts, and Congress led to reforms that forced researchers and pharmaceutical companies to diversify the population from which they drew for clinical research. That change has gone hand in hand with bold assertions that group differences in society are encoded in our biology—for example, that there are important biological differences in the ways that people of different races and sexes respond to drugs and other treatments.

While the prominence of these inclusive practices has offered hope to traditionally underserved groups, Epstein argues forcefully that it has drawn attention away from the tremendous inequalities in health that are rooted not in biology but in society. There is, for instance, a direct relationship between social class and health status—and Epstein believes that a focus on bodily differences can obscure the importance of this factor. Only when connected to a broad-based effort to address health disparities, Epstein explains, can a medical policy of inclusion achieve its intended effects.

With Science for Sale, acclaimed journalist Daniel S. Greenberg reveals that campus capitalism is more complicated—and less profitable—than media reports would suggest. While universities seek out corporate funding, news stories rarely note that those industry dollars are dwarfed by government support and other funds. Also, while many universities have set up technology transfer offices to pursue profits through patents, many of those offices have been financial busts. Meanwhile, science is showing signs of providing its own solutions, as highly publicized misdeeds in pursuit of profits have provoked promising countermeasures within the field.

But just because the threat is overhyped, Greenberg argues, doesn’t mean that there’s no danger. From research that has shifted overseas so corporations can avoid regulations to conflicts of interest in scientific publishing, the temptations of money will always be a threat, and they can only be countered through the vigilance of scientists, the press, and the public.

In Healthy Voices, Unhealthy Silence, Colleen M. Grogan and Michael K. Gusmano address these questions through the lens of state-level health care advocacy for the poor. They examine how representatives for the poor participate in an advisory board process by tying together existing studies; extensive interviews with key players; and an in-depth, first-hand look at the Connecticut Medicaid advisory board's deliberations during the managed care debate. Drawing on the concepts of deliberative democracy, agenda setting, and nonprofit advocacy, Grogan and Gusmano reveal the reasons behind advocates' often unexpected silence on major issues, assess how capable nonprofits are at affecting policy debates, and provide prescriptive advice for creating a participatory process that adequately addresses the health care concerns of the poor and dispossessed.

The distinctive mixing and continuous remixing of pub- lic and private roles is a defining feature of health care in the United States. The Public-Private Health Care State explores the interweaving of public and private enterprise in health care in the United States as a basis for thinking about health care in terms of its history and its continuing evolution today. Historian and policy analyst Rosemary Stevens has selected and edited seventeen essays from both her published and unpublished work to illustrate continuing themes, such as: the flexible meanings of the terms “public” and “private,” and how useful their ambiguity has been and is; the role of ideology as ratifying rather than preordaining change; and the common behavior of public leaders and corporate entities in the face of fiscal opportunity.

The topics—covering the period of 1870 through the twenty-first century—represent Stevens’ research interests in hospital history and policy, the medical profession, government policy, and paying for health care. The volume also considers her involvement with policy questions, which include health services research, health maintenance organizations, and physician workforce policy.

Section I demonstrates the long history of state government involvement with private not-for-profit hospitals from the 1870s through the 1930s. Section II examines the federal role in health care from the 1920s through the 1970s, including the establishment of veterans’ hospitals and the implementation of Medicaid. Section III shows how shifting governmental roles require constantly changing organizing rhetoric, whether for inventing a federal role for health services research and HMOs, “regionalization” in the 1970s, or defining civil rights and “equity” as mobilizing vehicles in the 1980s. Section IV examines growing concerns from the 1970s through the present about the traditional “public” role of the largely “private” medical profession. Section V returns to the ambiguous public-private status of not-for profit hospitals, buffeted in the 1980s and 1990s by assumptions about the efficiency of the market.

Nathanson shows how public health policies emerge out of battles over power and ideology, in which social reformers clash with powerful interests, from dairy farmers to tobacco lobbyists to the Catholic Church. Comparing the history of four public health dilemmas—tuberculosis and infant mortality at the turn of the last century, and more recently smoking and AIDS—in the United States, France, Britain, and Canada, Nathanson examines the cultural and institutional factors that shaped reform movements and led each government to respond differently to the same health challenges. She finds that concentrated political power is no guarantee of government intervention in the public health domain. France, an archetypical strong state, has consistently been decades behind other industrialized countries in implementing public health measures, in part because political centralization has afforded little opportunity for the development of grassroots health reform movements. In contrast, less government centralization in America has led to unusually active citizen-based social movements that campaigned effectively to reduce infant mortality and restrict smoking. Public perceptions of health risks are also shaped by politics, not just science. Infant mortality crusades took off in the late nineteenth century not because of any sudden rise in infant mortality rates, but because of elite anxieties about the quantity and quality of working-class populations. Disease Prevention as Social Change also documents how culture and hierarchies of race, class, and gender have affected governmental action—and inaction—against particular diseases.

Most experts would agree that the current medical malpractice system in the United States does not work effectively either to compensate victims fairly or prevent injuries caused by medical errors. Policy responses to a series of medical malpractice crises have not resulted in effective reform and have not altered the fundamental incentives of the stakeholders. In Medical Malpractice, economist Frank Sloan and lawyer Lindsey Chepke examine the U.S. medical malpractice process from legal, medical, economic, and insurance perspectives, analyze past efforts at reform, and offer realistic, achievable policy recommendations. They review the considerable empirical evidence in a balanced fashion and assess objectively what works in the current system and what does not. Sloan and Chepke argue that the complexity of medical malpractice stems largely from the interaction of the four discrete markets that determine outcomes--legal, medical malpractice insurance, medical care, and government activity. After describing what the evidence shows about the functioning of medical malpractice, types of defensive medicine, and the effects of past reforms, they examine such topics as scheduling damages as an alternative to flat caps, jury behavior, health courts, incentives to prevent medical errors, insurance regulation, reinsurance, no-fault insurance, and suggestions for future reforms.