https://www.zora.uzh.ch/id/eprint/191169/1/1-s2.0-S027795362030589X-main.pdf

Non-compliance with COVID-19-related public health measures among young adults in Switzerland: Insights from a longitudinal cohort study.

Many goods and services can be readily provided through a series of unconnected transactions, but in health care close coordination over time and within care episodes improves both health outcomes and efficiency. Close coordination is problematic in the US health care system because the financing and delivery of care is distributed across a variety of distinct and often competing entities, each with its own objectives, obligations and capabilities. These fragmented organizational structures lead to disrupted relationships, poor information flows, and misaligned incentives that combine to degrade care quality and increase costs. We illustrate our argument with examples taken from the insurance and the hospital industries, and discuss possible responses to the problems resulting from organizational fragmentation.

Organizational Fragmentation and Care Quality in the U.S. Health Care System

The financing and provision of health care in the United States is distrib uted across a variety of distinct and often competing entities, each with its own objectives, obligations, and capabilities. These fragmented organiza tional structures lead to disrupted relationships, poor information flows, and misaligned incentives that combine to degrade the quality of health care in impor tant ways. Many goods and services can be readily financed and provided through a series of unconnected transactions, but in health care, close coordination im proves both health outcomes and the efficiency with which good outcomes are achieved. In discussing the effect of organizational fragmentation on the quality of health care, it is helpful to separate the financing of health care from the provision of care. Medical expenditures over a lifetime are often large, lumpy, and uncertain,

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Organizational fragmentation and care quality in the U.S healthcare system.

Efforts to reform the American health care system through direct government action have failed repeatedly. This article evaluates an alternative strategy that has emerged from these experiences: requiring insurance organizations and health care providers to disclose information to the public. Mandatory disclosure laws have become a focal point of current health care regulation, particularly as a response to the growth of managed care. The article traces the current popularity of disclosure laws to several developments, ranging from technical advances in health policy research to changes in social attitudes towards government. The article identifies four arguments for mandatory disclosure in health care, associates each with evolving trends in the law, and analyzes their implications for public policy. The article reveals that the most commonly articulated goal of disclosure laws, improving the efficiency of private purchasing decisions by giving purchasers complete information about price and quality, is the most complicated operationally. Other justifications for disclosure laws hold greater promise, but make different, sometimes conflicting assumptions about sources and uses of information. For example, using disclosure to ensure that intermediaries upon whom patients and consumers rely are in fact serving their interests suffers from potentially crippling ambiguities because agency relationships in health care are not limited to contractable matters. Similarly, public disclosure can stimulate innovation and improve the performance of the health care system in achieving organizational and national goals, but setting those goals implies influencing rather than honoring consumer preferences. Finally, although information can expose to democratic deliberation the social tradeoffs implicit in current health policy -- including public investment and procedural fairness -- the welfare consequences of transparency are indeterminate. The lessons that emerge from the article's analysis have implications not only for health care, but for other regulated practices and industries.

Regulating Through Information: Disclosure Laws and American Health Care

Unlike the other contributions to this issue, this paper is concerned with the prospects and potential ramifications of implementing interprofessional practice from the legal standpoint. The author...

Regulatory and medico-legal barriers to interprofessional practice.

/pdf/what-federalism-means-for-the-us-response-to-coronavirus-591b5j66p9.pdf

What Federalism Means for the US Response to Coronavirus Disease 2019

Federalism has complicated the US response to the novel coronavirus. States' actions to address the pandemic have varied widely, and federal and state officials have provided conflicting messages. This fragmented approach has surely cost time and lives. Federalism will shape the long-term health and economic impacts of COVID-19, including plans for the future, for at least two reasons: First, federalism exacerbates inequities, as some states have a history of underinvesting in social programs, especially in certain communities. Second, many of the states with the deepest needs are poorly equipped to respond to emergencies due to low taxes and distrust of government, leading to inadequate infrastructure. These dynamics are not new, but they have been laid bare by this crisis. What can policy makers do to address the inequities in health and economic outcomes that federalism intensifies? The first section of this article offers a case study of the Mississippi Delta to illustrate the role of federalism in perpetuating the connection between place, health, and economics. The second section examines challenges that safety net programs will face when moving beyond the acute phase of COVID-19. The final section explores near-, middle-, and long-term policy options to mitigate federalism's harmful side effects.

/pdf/federalism-complicates-the-response-to-the-covid-19-health-5ey97bmfhi.pdf

Federalism Complicates the Response to the COVID-19 Health and Economic Crisis: What Can Be Done?

The Affordable Care Act (ACA) offers a window into modern American federalism--and modern American nationalism--in action. The ACA's federalism is defined not by separation between state and federal, but rather by a national structure that invites state-led implementation. As it turns out, that structure was only a starting point for a remarkably dynamic and adaptive implementation process that has generated new state-federal arrangements. States move back and forth between different structural models vis-a-vis the federal government; internal state politics produce different state choices; states copy, compete, and cooperate with each other; and negotiation with federal counterparts is a near constant. These characteristics have endured through the change in presidential administration. This Article presents the results of a study that tracked the details of the ACA's federalism-related implementation from 2012 to 2017. Among the questions that motivated the project: Does the ACA actually effectuate "federalism," and what are federalism’s key attributes when entwined with national statutory implementation? A federal law on the scale of the ACA presented a rare opportunity to investigate implementation from a statute's very beginning and to provide the concrete detail often wanting in federalism scholarship. The findings deconstruct assumptions about federalism made by theorists of all stripes, from formalist to modern. Federalism’s commonly invoked attributes--including autonomy, cooperation, experimentation, and variation--have not been dependent on any particular architecture of either state-federal separation or entanglement, even though theorists typically call on "federalism" to produce them. Instead, these attributes have been generated in ACA implementation across virtually every kind of governance model--that is, regardless whether states expand Medicaid; get waivers; or operate their own insurance exchanges or let the federal government do it for them. This makes it extraordinarily challenging to measure which structural arrangements are most "federalist," especially because the various federalism attributes are not always present together. The study also uncovers major theoretical difficulties when it comes to healthcare: Without a clear conception of the U.S. healthcare system’s goals, how can we know which structural arrangements serve it best, much less whether they are working? If healthcare federalism is a mechanism to produce particular policy outcomes, we should determine whether locating a particular facet of healthcare design in the states versus the federal government positively affects, for example, healthcare cost, access, or quality. If, instead, healthcare federalism serves structural aims regardless of policy ends--for instance, reserving power to states in the interest of sovereignty or checks and balances--we should examine whether it does in fact accomplish those goals, and we should justify why those goals outweigh the moral concerns that animate health policy. The ACA did not cause this conceptual confusion, but it retained and built on a fragmented healthcare landscape that already was riddled with structural and moral compromises. This does not mean that federalism is an empty concept or that it does not exist in the ACA. Federalism scholars tend to argue for particular structural arrangements based on prior goals and values. The ACA's architecture challenges whether any of these goals and values are unique to federalism or any particular expression of it. At the same time, the ACA's implementation is clearly a story about state leverage, intrastate democracy, and state policy autonomy within, not apart from, a national statutory scheme. Its implementation illustrates how federalism is a proxy for many ideas and challenges us to ask what we are really fighting over, or seeking, when we invoke the concept in healthcare and beyond.

/pdf/what-is-federalism-in-healthcare-for-3efddm4q0z.pdf

What Is Federalism in Healthcare For

Federalism has complicated the US response to the novel coronavirus. States’ actions to address the pandemic have varied widely, and federal and state officials have provided conflicting messages. This fragmented approach has cost time and lives. Federalism will shape the long-term health and economic impacts of COVID-19, including plans for the future, for at least two reasons: First, federalism exacerbates inequities, as some states have a history of underinvesting in social programs, especially in certain communities. Second, many of the states with the deepest needs are poorly equipped to respond to emergencies due to low taxes and distrust of government, leading to inadequate infrastructure. These dynamics are not new, but they have been laid bare by this crisis. What can policy makers do to address the inequities in health and economic outcomes that federalism intensifies? The first section of this article offers a case study of the Mississippi Delta to illustrate the role of federalism in perpetuating the connection between place, health, and economics. The second section examines challenges that safety net programs will face when moving beyond the acute phase of COVID-19. The final section explores near-, middle-, and long-term policy options to mitigate federalism’s harmful side effects.

/pdf/federalism-complicates-the-response-to-the-covid-19-health-22nap64jz3.pdf

Can Work Be Required in the Medicaid Program? The Trump administration is now encouraging states to develop work requirements for Medicaid eligibility. But this new policy conflicts with federal law, undermines the health of Medicaid beneficiaries, and will cause disenrollment.

Nicole Huberfeld

Papers

What Federalism Means for the US Response to Coronavirus Disease 2019

Federalism Complicates the Response to the COVID-19 Health and Economic Crisis: What Can Be Done?

What Is Federalism in Healthcare For

Federalism Complicates the Response to the COVID-19 Health and Economic Crisis: What Can Be Done?

Can Work Be Required in the Medicaid Program