Resource Allocation for Equity in the British National Health Service, 1948-89: An Advocacy Coalition Analysis of the RAWP

Hospital Expenditures Under Global Budgeting and Single-Payer Financing: An Economic Analysis, 2021-2030

U.S. hospitals provide large amounts of low-value care and devote inordinate resources to administration, while some hospitals leverage market power to realize large profits. Meanwhile, many rural and safety net hospitals are financially distressed. The coexistence of waste and want suggests that U.S. hospital financing is neither efficient nor equitable. We model the economic consequences of adopting the mode of hospital payment used in Canada and the U.S. Veterans Health Administration and proposed in the leading congressional single-payer Medicare-for-All bill: global budgeting. Our models assume increased utilization due to expanded and upgraded coverage; gradual reductions in administrative costs from simplified payment; and the elimination of hospital profits, with hospital capital expenditures funded by explicit grants rather than from profits or borrowing. We estimate that non-federal hospital operating budgets will total $17.2 trillion between 2021 and 2030 under current law versus $14.7 trillion under single-payer with global budgeting. This difference reflects $520 billion in foregone profits and $1,984 billion in reduced expenditures on hospital administration; expenditures on clinical operating budgets, however, would be higher than under current law, funded out of profits.

From "Honeymoon Period" to "Stable Marriage": The Rise of Management Consultants in British Health Policymaking

Since the creation of the National Health Service in 1948, different groups of experts have competed to inform the development of British health policy. This article analyzes the long-term rise of one of these groups-management consultants. The scale and regularity of their engagement has increased considerably over time, strikingly in recent years, and the functions fulfilled by consultants have become ever more diverse. At important moments they were often seen by policymakers-particularly when there was understood to be a lack of internal expertise-as possessors and imparters of important knowledge. Firms and individuals worked consciously to integrate themselves into emerging health policy networks. But there has often been relatively little consideration of their real suitability for work in the health field. Many debates around the use of external consultants today-accountability, value for money, dependency-were foreshadowed during earlier periods, with implications for current policymakers.

Structural Urbanism Contributes To Poorer Health Outcomes For Rural America

Rural populations disproportionately suffer from adverse health outcomes, including poorer health and higher age-adjusted mortality. We argue that these disparities are due in part to declining health care provider availability and accessibility in rural communities. Rural challenges are exacerbated by "structural urbanism"-elements of the current public health and health care systems that disadvantage rural communities. We suggest that biases in current models of health care funding, which treat health care as a service for an individual rather than as infrastructure for a population, are innately biased in favor of large populations. Until this bias is recognized, the development of viable models for care across the rural-urban continuum cannot move forward.

'Save our NHS': activism, information-based expertise and the 'new times' of the 1980s

This article examines activism in defence of the National Health Service (NHS), which emerges in the 1960s to defend local hospitals from closure. From the mid-1980s, a new form of campaigning developed, which sought to protect the Service nationally. Tracing this campaigning illuminates, first, that small groups played a significant role in negotiating political change, and in contributing to cultural change which, in turn, has become politically powerful. Second, this demonstrates that the 1980s were 'new times' in welfare politics, as Thatcher's changes fostered voluntary interest in information-led expertise, and a new vision of the NHS as a significant, much valued, national institution.

Quantifying life: Understanding the history of Quality-Adjusted Life-Years (QALYs)

Quality-Adjusted Life-Years (QALYs) are central to healthcare decision-making in Britain and abroad, yet their history is poorly understood. In this paper, we argue that a more in-depth and political history of the QALY is needed to allow a critical evaluation of its current dominance. Exploiting rich data from archives and 44 semi-structured interviews conducted between 2015 and 2018, we employ Multiple Streams Analysis to construct a complex and dynamic picture of how the idea of QALYs emerged and was adopted within UK health policy. Through its historical and political approach, the paper illuminates the relative roles in the policy-making process of experts (especially economists) and politicians as 'entrepreneurs' in the development of new ideas; how these were influenced by negotiation within established and emerging institutional structures; and the role of serendipity and crisis.