Policy entrepreneurship in the Social transformation of American Medicine The Rise of Managed Care and Managed Competition
Purpose of this article: • Explanation of ideas and actions of elites, the marketing innovations by policy entrepreneurs, to political and business leaders. • How are health policies successfully implemented?
History • 1960: Liberal reformers → federal initiatives to expand access to health care. The medical proffession manage to retain its cultural authority and improves its economic status. →→→ BECAUSE: Public policies empfasizes redistribution of resources, without reorganization.
1970: Tension Medical system Towards expansion VS Society and state requiring some means of control over medical expenditures
Conservatives and Liberals demand reform. • Economic incentives and market competition. • Star observes: emerging corporate transformation of medicine → diminishing power of physicians. • Finding ways to rationalize financing and delivery of systems. • HMO`s one of many reforms.
Two threads of corporate transformation of medicine: Horizontal integration Vertical Integration
1990: From undelivered to dominant form of health care organization. HMO`s become the standard for employer sponsored coverage.
Why interest for HMO`s, even after their poor start? • The explanation is divided to a decade before and after the publication of Starrs book: • President Nixons ”Health maintainance strategy”(1970-1971, the before decade) • Universal health insurance(Clinton administration 1993-1994) • Public and private initiatives, not independent.
Public <=> Private • Policy changes today => impact on policy alternatives in the future. • Pierson:” Policy changes creates legacies or feedback in two ways(Skocpol and Pierson):
Structural effects Resources and Incentives Social groups, governmental elites and mass public. Future change? Block sebsequent reforms Learning effects - Alter distribution of information Substantiv Situational Promotes Promotes/inhibits Reforms Reforms Policy Change
Two episodes that are critical for the rise of managed care, and market competition. • Regulatory reforms adapted by federal officials • Competition, stimulated by the rise of health maintenance organizations(HMO)
HMO`s gets support. • Right time, right place and right people/network. • Highly coverage in New York Times. • Washington, veteran insider. • High unemplayment • Rising health care costs • Economic boom; but still undercoverage and underinsurance.
How was this possible? • Social forces • Strategically placed individuals at critical junctures. • Context • Leadership • Ideas • Power • Attack on professional norms(AMA) • Verification via evidence. • Political mobilization
Results • Inflation in health care slows down. • Significant policy innovation within short time period.
Impact of Elwood and Enthovens efforts on Public policies IDEAS Public Private -Elites norms -Institutinal capasity -New stakeholders in the market approach