Policy entrepreneurship in Policy entrepreneurship in the Social transformation the Social transformation

of American Medicineof American Medicine

The Rise of Managed Care The Rise of Managed Care andand

Managed Competition Managed Competition

Purpose of this article:Purpose of this article:

Explanation of ideas and actions of Explanation of ideas and actions of elites, the marketing innovations by elites, the marketing innovations by policy entrepreneurs, to political and policy entrepreneurs, to political and business leaders.business leaders.

How are health policies successfully How are health policies successfully implemented? implemented?

HistoryHistory

1960: Liberal reformers 1960: Liberal reformers → federal → federal initiatives initiatives to expand access to health care. to expand access to health care.

The medical proffession manage to retain its cultural The medical proffession manage to retain its cultural authority and improves its economic status.authority and improves its economic status.

→→→ →→→ BECAUSEBECAUSE: : Public policies empfasizes Public policies empfasizes redistribution of resources, without reorganization. redistribution of resources, without reorganization.

1970: Tension 1970: Tension

Medical system Towards expansionMedical system Towards expansion

VSVS

Society and state requiring some Society and state requiring some means of control over medical means of control over medical expendituresexpenditures

Conservatives and Liberals demand Conservatives and Liberals demand reform.reform.

Economic incentives and market Economic incentives and market competition.competition.

Star observes: emerging corporate Star observes: emerging corporate transformation of medicine transformation of medicine → diminishing → diminishing power of physicians.power of physicians.

Finding ways to rationalize financing and delivery of Finding ways to rationalize financing and delivery of systems.systems.

HMO`s one of many reforms.HMO`s one of many reforms.

Two threads of corporate Two threads of corporate transformation of medicine:transformation of medicine:

Horizontal integrationHorizontal integration Vertical Vertical IntegrationIntegration

1990: From undelivered to dominant 1990: From undelivered to dominant form of health care organization. form of health care organization. HMO`s become the standard for HMO`s become the standard for employer sponsored coverage.employer sponsored coverage.

Why interest for HMO`s, even Why interest for HMO`s, even after their poor start?after their poor start?

The explanation is divided to a decade The explanation is divided to a decade before and after the publication of before and after the publication of Starrs book:Starrs book:

President Nixons ”Health President Nixons ”Health maintainance strategy”(1970-1971, maintainance strategy”(1970-1971, the before decade)the before decade)

Universal health insurance(Clinton Universal health insurance(Clinton administration 1993-1994) administration 1993-1994)

Public and private initiatives, not Public and private initiatives, not independent.independent.

Public Public <=> Private<=> PrivatePolicy changes today => impact on Policy changes today => impact on

policy alternatives in the future.policy alternatives in the future.Pierson:” Policy changes creates Pierson:” Policy changes creates

legacies or feedback in two legacies or feedback in two ways(Skocpol and Pierson): ways(Skocpol and Pierson):

Policy ChangePolicy Change

Structural effectsStructural effects- Resources and IncentivesResources and Incentives- Social groups, Social groups,

governmental elites and governmental elites and mass public.mass public.

Future change?Future change?

Block sebsequent reformsBlock sebsequent reforms

Learning effectsLearning effects- Alter distribution of - Alter distribution of information information

SubstantivSubstantiv Situational Situational

Promotes Promotes Promotes/inhibitsPromotes/inhibits

ReformsReforms ReformsReforms

Two episodes that are critical for Two episodes that are critical for the rise of managed care, and the rise of managed care, and

market competition.market competition.Regulatory reforms adapted by Regulatory reforms adapted by

federal officialsfederal officialsCompetition, stimulated by the rise Competition, stimulated by the rise

of health maintenance of health maintenance organizations(HMO)organizations(HMO)

HMO`s gets support.HMO`s gets support.

Right time, right place and right Right time, right place and right people/network.people/network.

Highly coverage in New York Times.Highly coverage in New York Times.Washington, veteran insider. Washington, veteran insider. High unemplayment High unemplayment Rising health care costsRising health care costsEconomic boom; but still Economic boom; but still

undercoverage and underinsurance.undercoverage and underinsurance.

How was this possible?How was this possible? Social forces Social forces Strategically placed Strategically placed

individuals at critical individuals at critical junctures.junctures.

ContextContext LeadershipLeadership IdeasIdeas PowerPower Attack on professional Attack on professional

norms(AMA)norms(AMA) Verification via evidence.Verification via evidence. Political mobilizationPolitical mobilization

Power

Ideas

Leadership

ResultsResults

Inflation in health care slows down.Inflation in health care slows down.Significant policy innovation within Significant policy innovation within

short time period.short time period.

Impact of Elwood and Enthovens Impact of Elwood and Enthovens efforts on Public policiesefforts on Public policies

IDEASIDEAS

PublicPublic PrivatePrivate

-Elites norms-Elites norms-Institutinal capasity-Institutinal capasity-New stakeholders in the market -New stakeholders in the market

approachapproach

THE ENDTHE END