Global Governance for Health: how to motivate political change?

In this article, we address a central theme that was discussed at the Durham Health Summit: how can politics be brought back into global health governance and figure much more prominently in discussions around policy? We begin by briefly summarizing the report of the Lancet - University of Oslo Commission on Global Governance for Health: 'The Political Origins of Health Inequity' Ottersen et al. In order to provide compelling evidence of the central argument, the Commission selected seven case studies relating to, inter alia, economic and fiscal policy, food security, and foreign trade and investment agreements. Based on an analysis of these studies, the report concludes that the problems identified are often due to political choices: an unwillingness to change the global system of governance. This raises the question: what is the most effective way that a report of this kind can be used to motivate policy-makers, and the public at large, to demand change? What kind of moral or rational argument is most likely to lead to action? In this paper we assess the merits of various alternative perspectives: health as an investment; health as a global public good; health and human security; health and human development; health as a human right; health and global justice. We conclude that what is required in order to motivate change is a more explicitly political and moral perspective - favouring the later rather than the earlier alternatives just listed.

Navigating Between Stealth Advocacy and Unconscious Dogmatism: The Challenge of Researching the Norms, Politics and Power of Global Health

Global health research is essentially a normative undertaking: we use it to propose policies that ought to be implemented. To arrive at a normative conclusion in a logical way requires at least one normative premise, one that cannot be derived from empirical evidence alone. But there is no widely accepted normative premise for global health, and the actors with the power to set policies may use a different normative premise than the scholars that propose policies - which may explain the 'implementation gap' in global health. If global health scholars shy away from the normative debate - because it requires normative premises that cannot be derived from empirical evidence alone - they not only mislead each other, they also prevent and stymie debate on the role of the powerhouses of global health, their normative premises, and the rights and wrongs of these premises. The humanities and social sciences are better equipped - and less reluctant - to approach the normative debate in a scientifically valid manner, and ought to be better integrated in the interdisciplinary research that global health research is, or should be.

Homo immunologicus: on the limits of critique

Through a discussion of a range of research drawn from the humanities and social sciences, and with a particular emphasis on work that tackles questions about the discourse of the life sciences, this paper considers some of the difficulties with research that aims to offer a critical analysis of immunology and its relationship to culture. It considers in particular arguments made on behalf of a biopolitical reading of the life sciences and, by examining the uncertain shift between discursive analysis and philosophical claim, it seeks to address some of the underlying assumptions made about the relations between different kinds of knowledge practice in the interplay between life science, philosophy and culture. Drawing on the work of Belgian philosopher of science Isabelle Stengers to consider the ways in which critical and philosophical appraisals of immunology adopt a characteristically modern stance in the way that they address the life sciences, it further seeks to characterise some of the limits that such forms of critique display.

Positive affect as coercive strategy: conditionality, activation and the role of psychology in UK government workfare programmes

Eligibility for social security benefits in many advanced economies is dependent on unemployed and underemployed people carrying out an expanding range of job search, training and work preparation activities, as well as mandatory unpaid labour (workfare). Increasingly, these activities include interventions intended to modify attitudes, beliefs and personality, notably through the imposition of positive affect. Labour on the self in order to achieve characteristics said to increase employability is now widely promoted. This work and the discourse on it are central to the experience of many claimants and contribute to the view that unemployment is evidence of both personal failure and psychological deficit. The use of psychology in the delivery of workfare functions to erase the experience and effects of social and economic inequalities, to construct a psychological ideal that links unemployment to psychological deficit, and so to authorise the extension of state-and state-contracted-surveillance to psychological characteristics. This paper describes the coercive and punitive nature of many psycho-policy interventions and considers the implications of psycho-policy for the disadvantaged and excluded populations who are its primary targets. We draw on personal testimonies of people experiencing workfare, policy analysis and social media records of campaigns opposed to workfare in order to explore the extent of psycho-compulsion in workfare. This is an area that has received little attention in the academic literature but that raises issues of ethics and professional accountability and challenges the field of medical humanities to reflect more critically on its relationship to psychology.

Critical neuroscience meets medical humanities

This programmatic theory paper sketches a conceptual framework that might inspire work in critical Medical Humanities. For this purpose, Kaushik Sunder Rajan's account of biocapital is revisited and discussed in relation to the perspective of a critical neuroscience. Critical neuroscience is an encompassing positioning towards the recent public prominence of the brain and brain-related practices, tools and discourses. The proposed analytical scheme has five focal nodes: capital, life, technoscience, (neoliberal) politics and subjectivity. A special emphasis will be placed on contemporary framings of subjectivity, as it is here where deep-reaching entanglements of personhood with scientific practice and discourse, medical and informational technologies, and economic formations are most evident. Notably, the emerging subject position of the 'prospective health consumer' will be discussed as it figures prominently in the terrain between neuroscience and other medico-scientific disciplines.

Risk taking in adversarial situations: Civilization differences in chess experts

The projections of experts in politics predict that a new world order will emerge within two decades. Being multipolar, this world will inevitably lead to frictions where civilizations and states will have to decide whether to risk conflict. Very often these decisions are informed if not taken by experts. To estimate risk-taking across civilizations, we examined strategies used in 667,599 chess games played over eleven years by chess experts from 11 different civilizations. We show that some civilizations are more inclined to settle for peace. Similarly, we show that once engaged in the battle, the level of risk taking varies significantly across civilizations, the boldest civilization using the riskiest strategy about 35% more than the most conservative civilization. We discuss which psychological factors might underpin these civilizational differences.

Politics of prevention: The emergence of prevention science

BACKGROUND

This article critically examines the political dimension of prevention science by asking how it constructs the problems for which prevention is seen as the solution and how it enables the monitoring and control of these problems. It also seeks to examine how prevention science has established a sphere for legitimate political deliberation and which kinds of statements are accepted as legitimate within this sphere.

METHODS

The material consists of 14 publications describing and discussing the goals, concepts, promises and problems of prevention science. The analysis covers the period from 1993 to 2012.

RESULTS

The analysis shows that prevention science has established a narrow definition of "prevention", including only interventions aimed at the reduction of risks for clinical disorders. In publications from the U.S. National Institute of Drug Abuse, the principles of prevention science have enabled a commitment to a zero-tolerance policy on drugs. The drug using subject has been constructed as a rational choice actor lacking in skills in exerting self-control in regard to drug use. Prevention science has also enabled the monitoring and control of expertise, risk groups and individuals through specific forms of data gathering. Through the juxtaposition of the concepts of "objectivity" and "morality", prevention science has constituted a principle of delineation, disqualifying statements not adhering to the principles of prevention science from the political field, rendering ethical and conflictual dimensions of problem representations invisible.

CONCLUSION

The valorisation of scientific accounts of drugs has acted to naturalise specific political ideals. It simultaneously marginalises the public from the public policy process, giving precedence to experts who are able to provide information that policy-makers are demanding. Alternative accounts, such as those based on marginalisation, poverty or discrimination are silenced within prevention science.

The neoliberal political economy and erosion of retirement security

The origins and trajectory of the crisis in the United States retirement security system have slowly become part of the discussion about the social, political, and economic impacts of population aging. Private sources of retirement security have weakened significantly since 1980 as employers have converted defined benefits precisions to defined contribution plans. The Center for Retirement Research (CRR) now estimates that over half of boomer generation retirees will not receive 70-80% of their wages while working. This erosion of the private retirement security system will likely increase reliance on the public system, mainly Social Security and Medicare. These programs, however, have increasingly become the targets of critics who claim that they are not financially sustainable in their current form and must be significantly modified. This article will focus on an analysis of these trends in the erosion of the United States retirement security system and their connection to changes in the United States political economy as neoliberal, promarket ideology, and policies (low taxes, reduced spending, and deregulation) have become dominant in the private and public sectors. The neoliberal priority on reducing labor costs and achieving maximum shareholder value has created an environment inimical to maintain the traditional system of pension and health care benefits in both the private and public sectors. This article explores the implications of these neoliberal trends in the United States economy for the future of retirement security.

Recommendations for including surgery on the public health agenda

BACKGROUND

Surgical care has made limited inroads on the public health and global health agendas despite increasing data showing the enormous need. The objective of this study was to survey interested members of a global surgery community to identify patterns of thought regarding barriers to political priority.

MATERIALS AND METHODS

All active members of the nongovernmental organization Surgeons OverSeas were surveyed and asked why surgical care is not receiving recognition and support on the public health and global health agenda. Responses were categorized using the Shiffman framework on determinants of political priority for global initiatives by two independent investigators, and the number of responses for each of the 11 factors was calculated.

RESULTS

Seventy-five Surgeons OverSeas members replied (75 of 176; 42.6% response rate). A total of 248 individual reasons were collected. The most common responses were related to external frame, defined as public portrayals of the issue (60 of 248; 24.2%), and lack of effective interventions (48 of 248; 19.4%). Least cited reasons related to global governance structure (4 of 248; 2.4%) and policy window (4 of 248; 1.6%).

CONCLUSIONS

This survey of a global surgery community identified a number of barriers to the recognition of surgical care on the global health agenda. Recommendations include improving the public portrayal of the problem; developing effective interventions and seeking strong and charismatic leadership.

Power and priorities: the growing pains of global health Comment on "Knowledge, moral claims and the exercise of power in global health"

Shiffman has argued that some actors have a great deal of power in global health, and that more reflection is needed on whether such forms of power are legitimate. Global health is a new and evolving field that builds upon the historical fields of public and international health, but is more multi-disciplinary and inter-disciplinary in nature. This article argues that the distribution of power in some global health institutions may be limiting the contributions of all researchers in the field.

Doing transformational change in the English NHS in the context of "big bang" redisorganisation

PURPOSE

The purpose of this paper is to examine a bold and ambitious scheme known as the North East transformation system (NETS). The principal aim of the NETS is the achievement of a step-change in the quality of health services delivered to people living in the North East region of England. The paper charts the origins of the NETS and its early journey before describing what happened to it when the UK coalition government published its proposals for unexpected major structural change in the NHS. This had a profound impact on the leadership and direction of the NETS and resulted in it taking a different direction from that intended.

DESIGN/METHODOLOGY/APPROACH

The research design took the form of a mixed methods, longitudinal 3.5-year study aimed at exploring transformational change in terms of content, context, process and outcomes. The sample of study sites comprised 14 NHS trusts in the North East region chosen to provide geographical coverage of the area and to reflect the scale, scope and variety of the bodies that formed part of the NETS programme. The qualitative component of the research, which the paper draws upon, included 68 semi-structured interviews, observational studies and focus groups. Data analysis made use of both deductive and inductive frameworks. The deductive framework adopted was Pettigrew et al.'s "receptive contexts for change" and four of the eight factors stood out as especially important and form the basis of the paper.

FINDINGS

The fate of the NETS was shaped and influenced by the eight factors comprising the Pettigrew et al. receptive contexts for change framework but four factors in particular stood out as being especially significant: environmental pressure, quality and coherence of policy, key people leading change, supportive organisational culture. Perhaps the most significant lesson from the NETS is that achieving whole systems change is particularly vulnerable to the vicissitudes of politics especially where that system, like the UK NHS, is itself subject to those very same pressures. Yet, despite having an enormous influence on health policy, the political context is frequently avoided in research or not regarded as instrumental in determining the outcomes in respect of transformational change.

RESEARCH LIMITATIONS/IMPLICATIONS

The chief limitation is the credibility and authenticity of the interviews captured at particular points in time. These formed the datebase for subsequent analysis. The authors sought to guard against possible bias by supplementing interviews with observational studies and focus groups as well as running two dissemination events at which emerging findings from the study were subjected to independent external scrutiny and comment. These events provided a form of validation for the key study findings.

PRACTICAL IMPLICATIONS

The research findings demonstrate the importance of context for the likely outcome and success of complex transformational change initiatives. These require time to become embedded and demonstrate results especially when focused on changing culture and behaviour. But, in practice, allowing sufficient time during which the organisation may remain sufficiently stable to allow the change intervention to run its course and become embedded and sustainable is highly problematic. The consequence is that bold and ambitious efforts like the NETS are not given the space and stability to prove themselves. Too often, politics and external environmental pressures intrude in ways that may prove dysfunctional and negative.

SOCIAL IMPLICATIONS

Unless a different approach to transformational change and its leadership and management is adopted, then changing the NHS to enable it to appear more responsive to changing health care needs and expectations will remain a cause for concern. Ultimately the public will be the losers if the NHS remains insensitive to changing needs and expectations. The patient experience was at the centre of the NETS programme.

ORIGINALITY/VALUE

The study is original insofar as no other has sought to evaluate the NETS independently and over a reasonable time period. The research design, based on a mixed-methods approach, is unusual in evaluations of this nature. The study's conclusions are not so original but their value lies in largely confirming and reinforcing the findings from other studies. It perhaps goes further in stressing the impact of politics on health policy and the negative consequences of constant organisational change on attempts to achieve deep change in the way the NHS is organised and led.

The politics of researching global health politics Comment on "Knowledge, moral claims and the exercise of power in global health"

In this comment, I build on Shiffman's call for the global health community to more deeply investigate structural and productive power. I highlight two challenges we must grapple with as social scientists carrying out the types of investigation that Shiffman proposes: the politics of challenging the powerful; and the need to investigate types of expertise that have traditionally been thought of as 'outside' global health. In doing so, I argue that moving forward with the agenda Shiffman sets out requires social scientists interested in the global politics of health to be reflexive about our own exercise of structural and productive power and the fact that researching global health politics is itself a political undertaking.

From body motion to cheers: Speakers' body movements as predictors of applause

•

Stick-figure animations of speakers were rated on different personality traits.

•

Ratings were related to the applause and the hecklings the speakers received.

•

Dominance, agreeableness and extraversion were notable predictors of applause.

•

People read socially relevant information from body motion.

Appearance cues and brief displays of behavior are related to people’s personality, to their performance at work and to the outcomes of elections. Thus, people present themselves to others on different communication channels, while their interaction partners form first impressions on the basis of the displayed cues. In the current study we examined whether people are able to read information from politicians’ body motion. For a rating experiment we translated short video clips of politicians giving a speech into animated stick-figures and had these animations rated on trustworthiness, dominance, competence and the Big Five personality dimensions. Afterwards we correlated the ratings with the applause and the hecklings that the speakers received throughout their entire speech. This revealed that speakers whose body movements were perceived as high on dominance, as high on extraversion and as low on agreeableness received more applause. Although the results obtained need support from additional studies they indicate that body motion is an informative cue in real life settings.

Case study: San Francisco's use of neighborhood indicators to encourage healthy urban development

Neighborhood indicators are quantitative measures of neighborhood quality, including measures of attributes such as crime, noise, proximity to parks, transit services, social capital, and student performance. In 2007 the San Francisco Department of Public Health, with broad public input, developed a comprehensive system of neighborhood indicators to inform, influence, and monitor decisions made by the Department of City Planning and other community development institutions. Local public agencies, businesses, and citizens' groups used the indicators to identify disparities in environmental and social conditions, inform and shape neighborhood land use plans, select appropriate sites for development projects, craft new environmental regulations, and justify demands on developers to make financial contributions to community infrastructure. Among other things, the use of indicators contributed to policies to prevent residential displacement, a city ordinance requiring stricter building ventilation standards in areas with high air pollution, and the redeployment of traffic police to high-injury corridors. Data that can be used to create neighborhood indicators are increasingly available, and participation by public health and health care institutions in the indicators' development, dissemination, and application could help improve several conditions that contribute to poor population health.

A spanner in the works? anti-politics in global health policy: Comment on "A ghost in the machine? politics in global health policy"

The formulation of global health policy is political; and all institutions operating in the global health landscape are political. This is because policies and institutions inevitably represent certain values, reflect particular ideologies, and preferentially serve some interests over others. This may be expressed explicitly and consciously; or implicitly and unconsciously. But it's important to recognise the social and political dimension of global health policy. In some instances however, the politics of global health policy may be actively denied or obscured. This has been described in the development studies literature as a form of 'anti-politics'. In this article we describe four forms of anti-politics and consider their application to the global health sector.

Voting for a personality: Do first impressions and self-evaluations affect voting decisions?

•

People rated themselves and video clips of politicians on personality.

•

People gave an estimate of the probability that they would vote for the politicians.

•

Ratings of some personality traits were strongly related to voting behavior.

•

For the preferred personality traits people gave themselves higher ratings.

•

People’s voting decisions may be guided by traits they value high in themselves.

Participants were asked to assess their own personality (i.e. Big Five scales), the personality of politicians shown in brief silent video clips, and the probability that they would vote for these politicians. Response surface analyses (RSA) revealed noteworthy effects of self-ratings and observer-ratings of openness, agreeableness, and emotional stability on voting probability. Furthermore, the participants perceived themselves as being more open, more agreeable, more emotionally stable, and more extraverted than the average politician. The study supports previous findings that first impressions affect decision making on important issues. Results also indicate that when only nonverbal information is available people prefer political candidates they perceive as having personality traits they value in themselves.

Service user involvement in practitioner education: Movement politics and transformative change

This paper will attempt to celebrate both key developments and best practice involving the users of health and social care services in programmes of practitioner education in a UK context, and offer a critical appraisal of the extent to which such initiatives meet some of the more transformative objectives sought by service user activists for change. The approach is largely that of a discussion paper but we will illustrate some of the themes relating to movement activism with selected data. These data relate to earlier research and two specially convened focus groups within the Comensus initiative at the University of Central Lancashire; itself constituted as a piece of participatory action research. We conclude that universities represent paradoxical sites for the facilitation of debate and learning relevant to key issues of social justice and change. As such, they are places that can impede or support movement aims. Particular strategic responses might be more likely to engender progressive outcomes. These ought to include the presence of critically engaged academic staff operating within a scholarly culture that fosters forms of deliberative democratic decision making.

Not just a man's world: women's political leadership in the American labor movement

Although women have long played an important role in working class struggles, most leadership positions in unions have been held by men. Organized labor's recent shift towards social movement unionism has lead to a sense of optimism among those pressing for more gender equality among labor's elite. Yet scholarship on gender and power in other settings, including political institutions, social movements, and formal organizations, suggests other factors may also play a role in determining women's leadership in labor unions. The current research, based on a rich dataset of 70 local unions, provides important insight into the political careers of women. Beyond an analysis of organized labor, this research has implications for understanding the interplay of gender and power in formal organizations and social movements more broadly.

Ideology and disease identity: the politics of rickets, 1929-1982

How can we assess the reciprocal impacts of politics and medicine in the contemporary period? Using the example of rickets in twentieth century Britain, I will explore the ways in which a preventable, curable non-infectious disease came to have enormous political significance, first as a symbol of socioeconomic inequality, then as evidence of racial and ethnic health disparities. Between the 1920s and 1980s, clinicians, researchers, health workers, members of Parliament and later Britain's growing South Asian ethnic communities repeatedly confronted the British state with evidence of persistent nutritional deficiency among the British poor and British Asians. Drawing on bitter memories of the 'Hungry Thirties', postwar rickets-so often described as a 'Victorian' disease-became a high-profile sign of what was variously constructed as a failure of the Welfare State; or of the political parties charged with its protection; or of ethnically Asian migrants and their descendants to adapt to British life and norms. Here I will argue that rickets prompted such consternation not because of its severity, the cost of its treatment, or even its prevalence; but because of the ease with which it was politicised. I will explore the ways in which this condition was envisioned, defined and addressed as Britain moved from the postwar consensus to Thatcherism, and as Britain's diverse South Asian communities developed from migrant enclaves to settled multigenerational ethnic communities.

Cortisol and politics: variance in voting behavior is predicted by baseline cortisol levels

Participation in electoral politics is affected by a host of social and demographics variables, but there is growing evidence that biological predispositions may also play a role in behavior related to political involvement. We examined the role of individual variation in hypothalamic-pituitary-adrenal (HPA) stress axis parameters in explaining differences in self-reported and actual participation in political activities. Self-reported political activity, religious participation, and verified voting activity in U.S. national elections were collected from 105 participants, who were subsequently exposed to a standardized (nonpolitical) psychosocial stressor. We demonstrated that lower baseline salivary cortisol in the late afternoon was significantly associated with increased actual voting frequency in six national elections, but not with self-reported non-voting political activity. Baseline cortisol predicted significant variation in voting behavior above and beyond variation accounted for by traditional demographic variables (particularly age of participant in our sample). Participation in religious activity was weakly (and negatively) associated with baseline cortisol. Our results suggest that HPA-mediated characteristics of social, cognitive, and emotional processes may exert an influence on a trait as complex as voting behavior, and that cortisol is a better predictor of actual voting behavior, as opposed to self-reported political activity.

Political determinants of Health: Lessons for Pakistan

There is much concern about the capacity of the health system of Pakistan to meet its goals and obligations. Historically, the political thrust has been absent from the health policy formulation and this is reflected in the low and stagnant public allocations to health. Successive political leaderships have averred from considering healthcare is a common good rather than a market commodity and health has not been recognized as a constitutional right. Over 120 of world's nation states have accepted health as a constitutional right but the 1973 Constitution of Pakistan does not mandate health or education as a fundamental right and the recently adopted 18th constitutional amendment missed the opportunity to extend access to primary health care as an obligation of the State. It is argued in this communication that missing from the calculations of policy formulation and agenda setting is the political benefits of providing health and other social services to underserved populations. Across the developing world, many examples are presented of governments undertaking progressive health reforms that bring services where none existed and subsequently reaping electoral benefit. The political determinant of healthcare will be realized when the political leaders of poorly performing countries can be convinced that embracing distributive policies and successfully bringing healthcare to the poor can be major factors in their re-elections.

The health financing transition: a conceptual framework and empirical evidence

Almost every country exhibits two important health financing trends: health spending per person rises and the share of out-of-pocket spending on health services declines. We describe these trends as a "health financing transition" to provide a conceptual framework for understanding health markets and public policy. Using data over 1995-2009 from 126 countries, we examine the various explanations for changes in health spending and its composition with regressions in levels and first differences. We estimate that the income elasticity of health spending is about 0.7, consistent with recent comparable studies. Our analysis also shows a significant trend in health spending - rising about 1 per cent annually - which is associated with a combination of changing technology and medical practices, cost pressures and institutions that finance and manage healthcare. The out-of-pocket share of total health spending is not related to income, but is influenced by a country's capacity to raise general revenues. These results support the existence of a health financing transition and characterize how public policy influences these trends.

Beyond leadership: political strategies for coordination in health policies

Health in All Policies (HiAP) promises to improve population health by harnessing the energies and activities of various sectors. Nevertheless, it faces well-documented bureaucratic obstacles and appears to require intersectoral governance if it is to be established. The basic problems of establishing intersectoral governance for HiAP are known to public administration and political science. On reading that literature, we find that the difficulty of establishing intersectoral governance for HiAP breaks down into two kinds of problems: that of establishing coordinated actions at all (coordination); and ensuring that they endure in changed political circumstances (durability). We further find that policymakers' solutions fall into three categories: visible ones of political will (e.g., plans and targets); bureaucratic changes such as the introduction of Health Impact Assessment or reorganization; and indirect methods such as data publication and support from outside groups to put pressure on the government. It can seem that Health in All Policies, like much of public health, depends on effective and committed policymakers but is vulnerable to changing political winds. The three kinds of strategies suggest how policymakers can, and do, create intersectoral governance that functions and persists, expanding the range of effective policy recommendations.

Can health equity survive epidemiology? Standards of proof and social determinants of health

OBJECTIVE

This article examines how epidemiological evidence is and should be used in the context of increasing concern for health equity and for social determinants of health.

METHOD

A research literature on use of scientific evidence of "environmental risks" is outlined, and key issues compared with those that arise with respect to social determinants of health.

RESULTS

The issue sets are very similar. Both involve the choice of a standard of proof, and the corollary need to make value judgments about how to address uncertainty in the context of "the inevitability of being wrong," at least some of the time, and to consider evidence from multiple kinds of research design. The nature of such value judgments and the need for methodological pluralism are incompletely understood.

CONCLUSION

Responsible policy analysis and interpretation of scientific evidence require explicit consideration of the ethical issues involved in choosing a standard of proof. Because of the stakes involved, such choices often become contested political terrain. Comparative research on how those choices are made will be valuable.

Lessons from early Medicaid expansions under health reform: interviews with Medicaid officials

BACKGROUND

The Affordable Care Act (ACA) dramatically expands Medicaid in 2014 in participating states. Meanwhile, six states have already expanded Medicaid since 2010 to some or all of the low-income adults targeted under health reform. We undertook an in-depth exploration of these six "early-expander" states-California, Connecticut, the District of Columbia, Minnesota, New Jersey, and Washington-through interviews with high-ranking Medicaid officials.

METHODS

We conducted semi-structured interviews with 11 high-ranking Medicaid officials in six states and analyzed the interviews using qualitative methods. Interviews explored enrollment outreach, stakeholder involvement, impact on beneficiaries, utilization and costs, implementation challenges, and potential lessons for 2014. Two investigators independently analyzed interview transcripts and iteratively refined the codebook until reaching consensus.

RESULTS

We identified several themes. First, these expansions built upon pre-existing state-funded insurance programs for the poor. Second, predictions about costs and enrollment were challenging, indicating the uncertainty in projections for 2014. Other themes included greater than anticipated need for behavioral health services in the expansion population, administrative challenges of expansions, and persistent barriers to enrollment and access after expanding eligibility-though officials overall felt the expansions increased access for beneficiaries. Finally, political context-support or opposition from stakeholders and voters-plays a critical role in shaping the success of Medicaid expansions.

CONCLUSIONS

Early Medicaid expansions under the ACA offer important lessons to federal and state policymakers as the 2014 expansions approach. While the context of each state's expansion is unique, key shared experiences were significant implementation challenges and opportunities for expanding access to needed services.

Motion cues that make an impression: Predicting perceived personality by minimal motion information

The current study presents a methodology to analyze first impressions on the basis of minimal motion information. In order to test the applicability of the approach brief silent video clips of 40 speakers were presented to independent observers (i.e., did not know speakers) who rated them on measures of the Big Five personality traits. The body movements of the speakers were then captured by placing landmarks on the speakers' forehead, one shoulder and the hands. Analysis revealed that observers ascribe extraversion to variations in the speakers' overall activity, emotional stability to the movements' relative velocity, and variation in motion direction to openness. Although ratings of openness and conscientiousness were related to biographical data of the speakers (i.e., measures of career progress), measures of body motion failed to provide similar results. In conclusion, analysis of motion behavior might be done on the basis of a small set of landmarks that seem to capture important parts of relevant nonverbal information.

•

Body movements of politicians making a speech were captured.

•

Short video clips of these speeches were rated on personality.

•

Motion cues were related to personality traits and measures of career progress.

•

Simple motion cues and simple cognitive processes may guide impression formation.

•

Simple motion cues may play an important role in human communication.

The association between county political inclination and obesity: Results from the 2012 presidential election in the United States

OBJECTIVE

We examined whether stable, county-level, voter preferences were significantly associated with county-level obesity prevalence using data from the 2012 US Presidential election. County voting preference for the 2012 Republican Party presidential candidate was used as a proxy for voter endorsement of personal responsibility approaches to reducing population obesity risk versus approaches featuring government-sponsored, multi-sectoral efforts like those recommended by the Centers for Disease Control Centers for Disease Control (CDC, 2009).

METHOD

Cartographic visualization and spatial analysis were used to evaluate the geographic clustering of obesity prevalence rates by county, and county-level support for the Republican Party candidate in the 2012 U.S. presidential election. The spatial analysis informed the spatial econometric approach employed to model the relationship between political preferences and other covariates with obesity prevalence.

RESULTS

After controlling for poverty rate, percent African American and Latino populations, educational attainment, and spatial autocorrelation in the error term, we found that higher county-level obesity prevalence rates were associated with higher levels of support for the 2012 Republican Party presidential candidate.

CONCLUSION

Future public health efforts to understand and reduce obesity risk may benefit from increased surveillance of this and similar linkages between political preferences and health risks.

Political, cultural and economic foundations of primary care in Europe

This article explores various contributing factors to explain differences in the strength of the primary care (PC) structure and services delivery across Europe. Data on the strength of primary care in 31 European countries in 2009/10 were used. The results showed that the national political agenda, economy, prevailing values, and type of healthcare system are all important factors that influence the development of strong PC. Wealthier countries are associated with a weaker PC structure and lower PC accessibility, while Eastern European countries seemed to have used their growth in national income to strengthen the accessibility and continuity of PC. Countries governed by left-wing governments are associated with a stronger PC structure, accessibility and coordination of PC. Countries with a social-security based system are associated with a lower accessibility and continuity of PC; the opposite is true for transitional systems. Cultural values seemed to affect all aspects of PC. It can be concluded that strengthening PC means mobilising multiple leverage points, policy options, and political will in line with prevailing values in a country.

Leading and managing an emergency department-A personal view

The emergency department (ED) is a "unique operation, optimized to exist at the edge of chaos". It is the responsibility of the leaders and managers of the ED to ensure that their teams work in an environment where they can deliver the best care to their patients. This environment is defined by people, system and place. People are the most important asset of the ED. One of the most important responsibilities of the ED leaders and managers (senior management) is to foster teamwork. They will also have to ensure that communication between team members is optimal and that there is a structure in place for conflict resolution. ED senior management should be aware of their team dynamics and know the "movers and shakers" in their organization. ED systems should be kept simple. One of the core businesses of an ED is contingency planning. ED senior management must plan, prepare, practice, review, analyze, assess and strategize for unexpected events. The ED physical environment has an impact on the flow of care being delivered to her patients. ED senior management must manage change. Change works only if it takes root in the hearts and minds of the organization's people. The quality of the leaders and managers of the ED will determine whether or not, their teams work in an environment where they can deliver the best care to their patients.

China's "Gene War of the Century" and Its Aftermath: The Contest Goes On

Following the successful cloning of genes for mostly rare genetic diseases in the early 1990s, there was a nearly universal enthusiasm that similar approaches could be employed to hunt down genes predisposing people to complex diseases. Around 1996, several well-funded international gene-hunting teams, enticed by the low cost of collecting biological samples and China's enormous population, and ushered in by some well-connected Chinese intermediaries, came to China to hunt down disease susceptibility genes. This alarmed and, in some cases, enraged many poorly funded Chinese scientists, who perceived them as formidable competitors. Some depicted foreign gene-hunters as greedy pilferers of the vast Chinese genetic gold mine, comparing it to the plundering of national treasures from China by invaders in the past, and called upon the government and their fellow countrymen to rise up and protect China's genetic gold mine. Media uproar ensued, proclaiming the imminent "gene war of the century." This article chronicles the key events surrounding this "war" and its aftermath, exposes some inherent complexities in identifying susceptibility genes for complex diseases, highlights some issues obscured or completely overlooked in the passionate and patriotic rhetoric, and debunks some misconceptions embedded in this conflict. In addition, it argues that during the entire course of this "war," the public's interest went conspicuously unmentioned. Finally, it articulates several lessons that can be learned from this conflict, and outlines challenges facing human genetics researchers.

State variability in children's Medicaid/CHIP crowd-out estimates

BACKGROUND

Health insurance crowd-out occurs when individuals enrolled in a public health insurance plan would have enrolled in a private plan but for the public option. The crowding-out of private insurance is often used to criticize state Medicaid and Children's Health Insurance Program (CHIP) expansion, as already insured children move their coverage to the states at the public's expense. A difficulty in discussing crowd-out comes from inconsistent estimates. Previous work focusing on the expansion of public programs has led to estimates ranging from 0% to 50% of the children newly insured on public plans being crowded-out.

METHODS

We apply a regression discontinuity approach to estimate how many children near the state Medicaid/CHIP threshold are crowded-out of private insurance. This approach allows estimates of crowd-out near the eligibility threshold independent of any expansion. Data from the American Community Survey's yearly survey of American households allows for state-level estimates of crowd-out.

RESULTS

We find considerable heterogeneity in the crowd-out that occurs in each state, ranging from no crowd-out to over 18% in states with similar eligibility thresholds. Additionally, we found that as state eligibility thresholds increase, children are less likely to be crowded-out.

DISCUSSION

This research indicates that national estimates of crowd-out are inappropriate, as state-specific Medicaid and CHIP programs have state-specific crowd-out. Additionally, it indicates that wealthier families that are eligible for public insurance are less likely to switch from private to public coverage than families earning less. Future work should identify reasons for the heterogeneity among states.

Financing long-term care for frail elderly in France: the ghost reform

Like many welfare states, France is faced with increasing demand for long term care (LTC) services. Public LTC coverage has evolved over the past 15 years, reaching a coverage depth of 70%. Nonetheless, it does not provide adequate and equitable financial protection for the growing number of frail elderly individuals, who are expected to constitute 3% of the population by the year 2060. Since 2005, various financing reform proposals have been debated, ranging from a newly covered risk under the social security system to targeted subsidies for private LTC insurance. However, to date no reform measure has been enacted. This article provides a brief history of publicly financed LTC in France in order to provide a context for the ongoing debate, including the positions and relative political power of the various stakeholders and the doubtful short-term prospect for reform.

Medicare readmission rates showed meaningful decline in 2012

OBJECTIVE

Descriptive analysis of 30-day, all-cause hospital readmission rate patterns from 2007-2012.

POPULATION

Medicare FFS beneficiaries experiencing at least one acute inpatient hospital stay.

METHODS

Using Chronic Condition Data Warehouse claims, we estimate unadjusted, monthly, readmission rates for the nation, within the Dartmouth Hospital Referral Regions (HRR), and compare participating and non-participating hospitals in the Partnership for Patients (P4P) program (overall and by number of inpatient beds at each facility).

RESULTS

From 2007 through 2011, the national 30-day, all-cause, hospital readmission rate averaged 19 percent. During calendar year 2012, the readmission rate averaged 18.4 percent. Of the 306 HRRs, rates in 166 HRRs fell by between 1 and 5 percent, while rates dropped by more than 5 percent in 73 HRRs, with the largest reduction in Longview, Texas. Rates increased by more than 1 percent in only 30 HRRs, with the largest increase in Bloomington, Illinois. Readmission rates at hospitals participating in the P4P program have been, on average, consistently lower than the rates at non-participating hospitals within all size categories except for the very smallest and largest hospitals, but rates at both participant and non-participant hospitals fell in 2012.

DISCUSSION

Although claims data are not yet final for 2012, our analysis indicates that hospital readmission rates for all Medicare FFS beneficiaries dropped noticeably during the year. The reasons behind the apparent reduction are not yet clear and merit further investigation.

The role of data in health care disparities in Medicaid managed care

BACKGROUND

The Affordable Care Act includes provisions to standardize the collection of data on health care quality that can be used to measure disparities. We conducted a qualitative study among leaders of Medicaid managed care plans, that currently have access to standardized quality data stratified by race and ethnicity, to learn how they use it to address disparities.

METHODS

We conducted semi-structured interviews with 21 health plan leaders across 9 Medicaid managed care plans in California. We used purposive sampling to maximize heterogeneity in geography and plan type (e.g., non-profit, commercial). We performed a thematic analysis based on iterative coding by two investigators.

RESULTS

We found 4 major themes. Improving overall quality was tightly linked to a focus on standardized metrics that are integral to meeting regulatory or financial incentives. However, reducing disparities was not driven by standardized data, but by a mix of factors. Data were frequently only examined by race and ethnicity when overall performance was low. Disparities were attributed to either individual choices or cultural and linguistic factors, with plans focusing interventions on recently immigrated groups.

CONCLUSIONS

While plans' efforts to address overall quality were often informed by standardized data, actions to reduce disparities were not, at least partly because there were few regulatory or financial incentives driving meaningful use of data on disparities. Standardized data, as envisaged by the Affordable Care Act, could become more useful for addressing disparities if they are combined with policies and regulations that promote health care equity.

CHIP reporting in the CPS

OBJECTIVE

To assess the quality of the Current Population Survey's (CPS) Child Health Insurance Program (CHIP) data.

DATA SOURCES

Linked 2000-2004 Medicaid Statistical Information System (MSIS) and the 2001-2004 CPS.

DATA COLLECTION METHODS

Centers for Medicare & Medicaid Services provided the Census Bureau with its MSIS file. The Census Bureau linked the MSIS to the CPS data within its secure data analysis facilities.

STUDY DESIGN

We compared responses to the CPS health insurance items with Medicaid and CHIP status according to the MSIS.

PRINCIPAL FINDINGS

CHIP reporting in the CPS is unreliable. Only 10-30 percent of those with CHIP (but not Medicaid) report this type of coverage in the CPS. Many with CHIP report Medicaid coverage, so the reporting error for a Medicaid-CHIP composite is smaller, but still substantial.

CONCLUSIONS

The quality of the CPS CHIP information renders it effectively unusable for health policy analysis. Analysts should consider using a Medicaid-CHIP composite for CPS-based analyses.

Statistical uncertainty in the Medicare shared savings program

OBJECTIVE

Analyze statistical risks facing CMS and Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program (MSSP).

METHODS

We calculate the probability that shared savings formulas lead to inappropriate payment, payment denial, and/or financial penalties, assuming that ACOs generate real savings in Medicare spending ranging from 0-10%. We also calculate expected payments from CMS to ACOs under these scenarios.

RESULTS

The probability of an incorrect outcome is heavily dependent on ACO enrollment size. For example, in the MSSP two-sided model, an ACO with 5,000 enrollees that keeps spending constant faces a 0.24 probability of being inappropriately rewarded for savings and a 0.26 probability of paying an undeserved penalty for increased spending. For an ACO with 50,000 enrollees, both of these probabilities of incorrect outcomes are equal to 0.02. The probability of inappropriate payment denial declines as real ACO savings increase. Still, for ACOs with 5,000 patients, the probability of denial is at least 0.15 even when true savings are 5-7%. Depending on ACO size and the real ACO savings rate, expected ACO payments vary from $115,000 to $35.3 million.

DISCUSSION

Our analysis indicates there may be greater statistical uncertainty in the MSSP than previously recognized. CMS and ACOs will have to consider this uncertainty in their financial, administrative, and care management planning. We also suggest analytic strategies that can be used to refine ACO payment formulas in the longer term to ensure that the MSSP (and other ACO initiatives that will be influenced by it) work as efficiently as possible.

'Proper motions, actions and uses': physiological knowledge as the only means to rational politics in Restoration England

This article is drawn from a doctoral thesis called ‘Governing Public Bodies: Reconsidering the Relationship Between Statecraft and Healthcare in England, 1650–1730’, which considers two things: how certain categories of person, certain subjectivities, have been assembled through government in the name of health; and how the health of the individual has been understood to relate to that of the collective.