The Pay-Twice Critique, Government Funding, and Reasonable Pricing Clauses

The federal government subsidizes the research and development of prescription medications. Thus, a captivating critique of expensive medications is that prices are too high because of taxpayer co-financing. This critique is often framed in terms of "paying-twice"-first for the research and second through the above market pricing of resulting products. Reasonable pricing clauses-which place some kind of pricing limitation on the exercise of license or patent rights governing a federally funded medication-are one proposed policy tool for addressing the pay-twice critique. This article provides increased analytical clarity as well as historical context to present-day debates about the privatization of federally funded research and prescription drug pricing. It makes three arguments. First, despite its pervasiveness and intuitive plausibility, the pay-twice critique is subject to differing interpretations which has important implications for the appropriateness of proposed solutions. Second, despite their initial attractiveness, the costs, necessity, and effectiveness of reasonable pricing clauses render the wisdom of this policy tool uncertain. However, third, given continued interest in reasonable pricing clauses, the NIH's previous experience with such a policy offers some useful lessons.

[Assessment of prescriptive therapies and remedies - Experience and results]

In the years 2005-2015, a leading assessment institute conducted numerous assessments on behalf of two major German private health insurance companies concerning the necessity of prescriptive therapies and remedies. The findings are presented in this article, and the results vary significantly, depending on the prescriptive therapy assessed.

Basic sanitation policy in Brazil: discussion of a path

This article demonstrates that the position of dominance enjoyed by state sanitation companies dictates the public policy decision-making process for sanitation in Brazil. These companies' hegemony is explained here through the analysis of a path that generated political and economic incentives that have permitted its consolidation over time. Through the content analysis of the legislation proposed for the sector and the material produced by the stakeholders involved in the approval of new regulations for the sector in 2007, the study identifies the main sources of incentive introduced by the adoption of the National Sanitation Plan, which explain certain structural features of the current sanitation policy and its strong capacity to withstand the innovations proposed under democratic rule.

"The Google of Healthcare": enabling the privatization of genetic bio/databanking

PURPOSE

23andMe is back on the market as the first direct-to-consumer genetic testing company that "includes reports that meet Food and Drug Administration (FDA) standards…." But, whereas its front-end product is selling individual genetic tests online, its back-end business model is amassing one of the largest privately owned genetic databases in the world. What is the effect, however, of the private control of bio/databases on genetic epidemiology and public health research?

METHODS

The recent federal government notices of proposed rulemaking for: (1) revisions to regulations governing human subjects research and (2) whether certain direct-to-consumer genetic tests should require premarket FDA review, were reviewed and related to the 23andMe product, business model, and consumer agreements.

RESULTS

FDA regulatory action so far has focused on the return of consumer test reports but it should also consider the broader misuse of data and information not otherwise protected by human subjects research regulations.

CONCLUSIONS

As the federal government revises its decades-old human subjects research structure, the Executive Office of the President (EOP) should consider a cohesive approach to regulating private genetic bio/databanks. This strategy should allow the FDA and other agencies to play a role in expanding current regulatory coverage.

Neoliberal and Public Health Effects of Failing to Adopt Osha's National Secondhand Tobacco Smoke Rule

From the early 1980s to the present, neoliberal doctrine has called for government policies of privatization, funding cutbacks, and deregulation of public health and other domestic social programs in the belief that the market rather than the public sector can best organize and distribute crucial societal services. Proponents of a neoliberal and deregulatory mixed approach of command and control and self-regulation argue this approach provides the most adequate means to conduct regulation in the legalistic and adversarial U.S. regulatory process. In April 1994, the Occupational Safety and Health Administration issued a proposed rule to eliminate tobacco smoking in most workplace rooms, arguing secondhand tobacco smoke annually killed up to 13,700 nonsmokers. The tobacco industry purposely delayed public hearing procedures (later halted altogether by Congress and the president) primarily to advance unhindered private property rights and profits rather than submitting to a public command-and-control regulatory framework to reduce deaths due to secondhand tobacco smoke.

Argentina: No Lesson Learned

This article examines the political, ideological, social, and economic processes by which the Argentinean economy was transformed, the structural consequences, and the policies responsible for dismantling the welfare state. The health care system reform during the 1990s was an important component in accomplishing the last objective. Analyses of the policies adopted after the crisis of 2001 reveal that, despite the discourse against international financial institutions, President Nestor Kirchner, elected in 2002, followed the same approach by accepting and applying the second generation of health reforms recommended by the World Bank and the Inter-American Development Bank with additional pressure from the World Trade Organization and several free trade agreements. This “new reform” furthered business opportunities for multinational corporations while further shrinking the state administration's role in supplying health, education, and other social services to people who need them more than ever. Social movements have emerged that are developing alternative projects and showing that, when the base is solidarity, “another world is possible.”

The World Health Situation

This article, based on a speech given at the Sixth IUHP European Conference on Health Promotion and Education, describes the consequences of the concentration of economic, political, and cultural power in the world today (in the countries of both North and South) for the health and well-being of the world population. The author stresses that the current world disorder is based on a set of alliances between the dominant classes (and economic and financial groups) of the North and the dominant classes (and groups) of the South against redistributional policies that would adversely affect their interests. This situation hurts the health and well-being of the dominated classes and other social groups of both North and South.

The International Monetary Fund and World Bank in Africa: A “Disastrous” Record

In their 60th anniversary year, the International Monetary Fund and World Bank will attempt to highlight their “assistance” to Africa. But in reality, since the 1970s, these institutions have gradually become the chief architects of policies that are responsible for the worst inequalities and the explosion of poverty in the world, especially in Africa. When they began to intervene on that continent in the late 1970s and early 1980s, their stated goal was to “accelerate development.” But the actual record is just disastrous, as this article reveals.

Analysis of Price Changes in Washington Following the 2012 Liquor Privatization

AIMS

In June, 2012 the state of Washington ended a wholesale and retail monopoly on liquor sales resulting in about five times as many stores selling liquor. Three-tier restrictions were also removed on liquor, while beer and wine availability did not increase. Substantial taxes at both the wholesale and retail levels were implemented and it was expected that prices would rise.

METHODS

To evaluate price changes after privatization we developed an index of about 68 brands that were popular in Washington during early 2012. Data on final liquor prices (including all taxes) in Washington were obtained through store visits and on-line sources between November 2013 and March of 2014. Primary analyses were conducted on five or six brand indexes to allow the inclusion of most stores.

RESULTS

Washington liquor prices rose by an average of 15.5% for the 750 ml size and by 4.7% for the 1.75 l size, while only small changes were seen in the bordering states of Oregon and Idaho. Prices were found to vary greatly by store type. Liquor Superstores had generally the lowest prices while drugstore, grocery and especially smaller Liquor Store prices were found to be substantially higher.

CONCLUSION

Our findings indicate that liquor prices in Washington increased substantially after privatization and as compared to price changes in bordering states, with a much larger increase seen for the 750 ml size and with wide variation across store types. However, persistent drinkers looking for low prices will be able to find them in certain stores.

The Health Legislation Amendment Act 2013 (QLD) and Queensland's health assets privatisation dispute

'New legislation in Queensland has provided a "pathway" for the privatisation of health assets and services in Queensland, which effectively realigns the health care system to the financial market. This column explores how this legislation contained the antecedents of the Queensland doctors' dispute when doctors roundly rejected new employment contracts in February 2014. It also argues that such legislation and its attendant backlash provides a valuable case study in view of the federal government's 2014 budget offer to the States of extra funding if they sell their health assets to fund new infrastructure. The move to privatise health in Queensland has also resulted in a government assault on the ethical credibility of the opposing medical profession and changes to the health complaints system with the introduction of a Health Ombudsman under ministerial control. The column examines these changes in light of R (Heather) v Leonard Cheshire Foundation [2001] EWHC Admin 429, a case concerning the obligations of a private entity towards publically funded clients in the United Kingdom. In discussing concerns about the impact of privatisation on the medical profession, the column points to a stark conflict between the duty to operate hospitals as a business rather than as a duty to patients.

The modernization of American public law: health care reform and popular constitutionalism

The Patient Protection and Affordable Care Act (ACA) transformed U.S. public law in crucial ways extending far beyond health care. As important as were the doctrinal shifts wrought by National Federation of Independent Business v. Sebelius, the ACA's structural changes to public law likely will prove far more important should they become entrenched. The struggle over the ACA has triggered the kind of "constitutional moment" that has largely replaced Article V's formal amendment procedure since the Prohibition fiasco. The Court participates in this process, but the definitive and enduring character of these constitutional moments' outcomes springs from broad popular engagement. Despite the Court's ruling and the outcome of the 2012 elections, the battle over whether to implement or shelve the ACA will continue unabated, both federally and in the states, until We the People render a clear decision. Whether the ACA survives or fails will determine the basic principles that guide the development of federalism, social insurance, tax policy, and privatization for decades to come. In each of these areas, the New Deal bequeathed us a delicate accommodation between traditionalist social values and modernizing norms of economic efficiency and interest group liberalism. This balance has come under increasing stress, with individual laws rejecting tradition far more emphatically than the New Deal did. But absent broad popular engagement, no definitive new principles could be established. The ACA's entrenchment would elevate technocratic norms across public law, the first change of our fundamental law since the civil rights revolution. The ACA's failure would rejuvenate individualistic, moralistic, pre-New Deal norms and allow opponents to attempt a counterrevolution against technocracy.

Commissions of audit in Australia: health system privatisation directives and civil conscription protections

The use of commissions of audit as vehicles to drive privatisation policy agendas in areas such as health service delivery has become popular with conservative federal and State governments. Such commissions have characteristically been established early in the terms of such governments with carefully planned terms of reference and membership. The policy directions they advocate, unlike election policies, have not come under the intense scrutiny, wide public debate or the opportunities for (dis)endorsement afforded by the electoral process. Governments do, however, anticipate and often accept recommendations from these reviews, and use them as justification to implement policy based on their findings. This highlights the power entrusted to review bodies and the risks to the public interest arising from limited public consultation. An example can be seen in the proposed privatisation of important aspects of Australia's public sector, particularly including those related to health systems delivery, currently entering a new iteration through the work of the National Commission of Audit appointed in October 2013. The NCA follows on from various State audit commissions which in recent years have directed the divestment of government responsibilities to the private and not-for-profit sectors. Through a discussion on the formation of policy frameworks by the NCA and the Queensland Commission of Audit, this column examines the ideological thrust of the commissions and how they synergise to produce a national directive on the future of public sector health services. The practical impacts on health service procurement and delivery in critical areas are examined, using the case of the federally contracted out medical service for asylum seekers and two hospitals in Western Australia, a State which is well advanced in the privatisation of public hospitals. The column then examines the release to the media early in the NCA's process of the submission to introduce a $6 general practitioner co-payment as a means of testing the response of the medical profession and public. The column also examines how the civil conscription clause in s 51 (xxiiiA) of the Australian Constitution may serve to protect practitioner and patient rights should some of these privatisation changes to Australia's health system be challenged in the High Court of Australia.

Is there a human right to private health care?

In recent years we have noticed an increase in the turn to rights analysis in litigation relating to access to health care. Examining litigation, we can notice a contradiction between on the one hand the ability of the right to health to reinforce privatization and commodification of health care, by rearticulating claims to private health care in terms of human rights, and on the other hand, its ability to reinforce and reinstate public values, especially that of equality, against the background of privatization and commodification. While many hope that rights discourse will do the latter, and secure that access to health care should occur on the basis of need as opposed to ability to pay, it has actually been used to attempt to advance arguments that will allow access to private or semiprivate health insurance in ways that may exacerbate inequality. These types of arguments won ground in the Canadian Supreme Court, but were rejected by the Israeli Supreme Court. In order to avoid this co-optation of right to health, a notion of rights that incorporates the principles of substantive equality is required. Otherwise, one of the unintended consequences of inserting rights analysis into public health care may be that it will reinforce rather than challenge privatization in a way that may increase inequalities.

Urban governance and spatial inequality in service delivery: a case study of solid waste management in Abuja, Nigeria

Spatial inequality in service delivery is a common feature in African cities. Several factors account for the phenomenon but there is growing attention towards urban governance and the role of the state. Urban governance policies such as privatization serve as key strategies through which the state regulates and (re)produces spatial inequality in service delivery. This study examined how governance practices related to privatization and the regulatory role of the state reinforce spatial inequalities in the delivery of solid waste services in Abuja, Nigeria. It focused primarily on the issue of cost recovery. Privatization became a major focus in Abuja in 2003 when the government launched a pilot scheme. Although it has brought improvements in service delivery, privatization has also increased the gap in the quality of services delivered in different parts of the city. Drawing on empirical data, the study revealed that little sensitivity to income and affordability, and to income differentials between neighbourhoods in the fixing of user charges and in the choice of the billing method is contributing to spatial inequalities in service delivery. Furthermore, the study suggests that these practices are linked to a broader issue, a failure of the government to see the people as partners. It therefore calls for more inclusive governance especially in decision-making processes. The study also emphasizes the need for a policy document on solid waste management, as this would encourage a critical assessment of vital issues including how privatization is to be funded, especially in low-income areas.

[Reform of forensic autopsy in the German Code of Criminal Procedure]

The Federal Ministry of Justice has presented another proposal to rephrase the wording of Section 87 of the German Code of Criminal Procedure (StPO). The new version of Section 87 StPO is to be rejected as it would lead to a loss of institutional and professional standards. The bill is clearly influenced by a tendency towards privatisation for the benefit of a small group of specialists in forensic medicine mostly organised in limited liability companies and thus at the expense of institutes of legal medicine affiliated to universities or physicians working in the forensic service of regional courts. In the long run, this reform would not only jeopardize medicolegal research and teaching but also medical education and specialist medical training. For future severe negative consequences would have to be expected on the rule of law and legal certainty.

The future of urban water services in Latin America

In recent decades, problems with the provision of drinking water and sanitation services around the world have increasingly been addressed by attempts at privatisation, recasting clean water as an essentially economic, rather than public, good. This approach gained particular acceptance in Latin America, but with limited success. In order to address the full range of social, economic and environmental values necessary to sustain water resources over time, public and governmental involvement in establishing integrated water management, pursuing ‘soft path’ approaches, assuring stakeholder input and setting policy will be essential to the process.

A new inequality? Privatisation, urban bias, migration and medical tourism

Access to health care in developing countries, the main destinations of medical tourists, is notoriously uneven, and often becoming more so. Medical tourism, urban bias and privatisation have combined to exacerbate this trend. This is exemplified in both Thailand and India, where regional areas have been disadvantaged by the migration of health-care workers to hospitals focusing on medical tourism, neo-liberal national financial provision for medical tourism (and related tourism campaigns) and evidence of trickle-down gains is lacking. Medical tourism challenges rather than complements local health care providers, distorts national health care systems, and raises critical national economic, ethical and social questions.

Shifting subjects of health-care: placing "medical tourism" in the context of Malaysian domestic health-care reform

"Medical tourism" has frequently been held to unsettle naturalised relationships between the state and its citizenry. Yet in casting "medical tourism" as either an outside "innovation" or "invasion," scholars have often ignored the role that the neoliberal retrenchment of social welfare structures has played in shaping the domestic health-care systems of the "developing" countries recognised as international medical travel destinations. While there is little doubt that "medical tourism" impacts destinations' health-care systems, it remains essential to contextualise them. This paper offers a reading of the emergence of "medical tourism" from within the context of ongoing health-care privatisation reform in one of today's most prominent destinations: Malaysia. It argues that "medical tourism" to Malaysia has been mobilised politically both to advance domestic health-care reform and to cast off the country's "underdeveloped" image not only among foreign patient-consumers but also among its own nationals, who are themselves increasingly envisioned by the Malaysian state as prospective health-care consumers.

State capacity: the missing piece in child welfare privatization

Privatization has been used to address the limited capacity of government to achieve positive results in child welfare systems. Privatized systems have not realized better outcomes than their public counterparts, however, and many states continue to struggle with implementation. In order to demonstrate that privatization is in fact an investment on the part of the state, rather than a solution to limited public resources, this article explores the relationship between state capacity and privatization and makes recommendations for more effective partnerships between the public and private sectors.

Patents, innovation, and privatization: Commentary on: "Data management in academic settings: an intellectual property perspective"

The framers of the U.S. Constitution believed that intellectual property rights were crucial to scientific advancement. Yet, the framers also recognized the need to balance innovation, privatization, and public use. The courts' expansion of patent protection for biotechnology innovations in the last 30 years raises the question whether the patent system effectively balances these concerns. While the question is not new, only through a thorough and thoughtful examination of these issues can the current system be evaluated. It is then a policy decision for Congress if any change is necessary.

Is a flat-line a good thing? On the privatization of Israel's healthcare system

Israel presents an intriguing conundrum: on the one hand, it provides quality healthcare in a near-universal healthcare system; on the other, it has maintained healthcare costs level at approximately 7.7% of GDP. This comes at a time when all western nations struggle with one or both sides of the equation: how to offer affordable, good quality health care to the population while curbing the sharp rise in health related costs. This paper explains both how Israel has achieved this 'flat line" effect and the social and political costs of this achievement.

The economics and ethics of Hurricane Katrina

How might free enterprise have dealt with Hurricane Katrina and her aftermath. This article probes this question at increasing levels of radicalization, starting with the privatization of several government “services” and ending with the privatization of all of them.

Extension services and multifunctional agriculture. Lessons learnt from the French and Dutch contexts and approaches

Today's acknowledgement of the multifunctionality of agriculture (MFA) implies the production of new knowledge to integrate different functions at farm level (primary production, environmental protection, food safety, etc.). At the same time, agricultural sectors of European countries have recently faced changes in the organisation of their R&D activities, including a trend of commercialisation and privatisation of advisory services for farmers. To assess the consequences of these changes on support for innovations related to MFA, this paper explores the potential of combining two analytical frameworks: an institutional economic approach (IEA) and a sociological network approach (SNA). This potential is illustrated by a historical analysis of advisory services in France and The Netherlands from 1945 until now. This analysis stresses the importance of collective procedures for the accumulation of technical knowledge in agriculture. It also shows that these procedures could not be analysed from a strictly technical perspective. They are the expression of institutional arrangements involving social groups of farmers and the state, and are grounded in national contexts. A historical perspective also enables us to understand better why the privatisation of extension services cannot meet the requirements of support for farm innovations in the MFA context.

Not the next IRA: how health savings accounts shape public opinion

Scholars suspect that public policies affect public opinion, but the empirical evidence is mixed, and contemporary theories advance offsetting predictions. This study examines two allegedly similar private investment account programs that differ in politically relevant ways. Statistical analyses show that owners of Individual Retirement Accounts (IRAs) and Health Savings Accounts (HSAs) experience policy feedback effects, but in opposite directions. More specifically, matched comparisons of respondents in a national survey indicate that IRA participants are more likely to favor Social Security privatization than individuals without IRAs. In contrast, HSA participants are less likely to prefer consumer-driven health coverage in which individuals are empowered to make choices. Overall, the findings suggest that policies alter public opinion preferences but that the effects depend on programmatic design and performance.