Recently, Congress has focused on reforms to address pharmacy benefit managers’ (PBMs) role in high drug prices for patients. Congress must not excessively restrict PBMs’ ability to negotiate with manufacturers; alternatively, reforms could be paired with other policies that address the high prices of brand-name drugs.

Despite historic efforts to enact the Patient Protection and Affordable Care Act in 2010, national health reform is threatened by multiple legal challenges grounded in constitutional law. Premier among these claims is the premise that PPACA’s “individual mandate” is constitutionally infirm. Attorneys General in Virginia and Florida allege that Congress’ interstate commerce powers do not authorize federal imposition of the individual mandate because Congress lacks the power to regulate commercial “inactivity.” Stated simply, Congress cannot regulate individuals who choose not to (...) obtain health insurance because they are not engaged in a commercial venture. Several courts initially considering this argument have rejected it, but two federal district courts in Virginia and Florida have concurred, leading to numerous appeals and the near promise of United States Supreme Court review. (shrink)

On May 3, 1999, at the Cato sponsored conference, "Forfeiture Reform: Now, or Never?", Representative Henry Hyde announced that he was, once again, introducing Forfeiture Reform legislation to Congress. For six years, he has been trying to get legislation passed that would..

An empirical exploration of the effects on legislative structure, distribution of influence, power, and decision outcomes, of recent changes in the Congress and state legislatures. The book focuses on changes in rules, parties, and committees and the impact or lack of impact of these changes on subsequent activity. Originally published in 1978 by D.C. Heath and Company. Co-published with the Policy Studies Organization.

Finding “common ground” to fix some of the policy problems with the ACA was never expected to be easy. How challenging depends on the election outcome. With split government or even same party control of the Congress and White House but without a supermajority in the Senate, fixing identifiable problems requires remedies that might garner bipartisan cooperation. Some potential strategies that might meet this requirement are described.

Presidential power has provoked increasingly vigorous debate since the turn of this century. In recent years, scholars and lawyers have been grappling with how Congress’s dictates may limit the president’s Commander-in-Chief power to detain enemy combatants at Guantanamo Bay, to fight wars abroad, and to conduct intelligence activities at home. But policymakers have not yet explored the many possibilities for invoking the president’s “Take Care” power to change health care policy.This article explores the scope and limits of President Barack Obama’s (...) ability to invoke his executive authority to reform health care. Specifically, it identifies ways the Obama Administration can use directives to: expand Medicaid and State Children’s Health Insurance Program coverage through section 1115 waivers; test quality initiatives through Medicare demonstration authority; expand health information technology; allow drug reimportation and experiment with contracting power under Medicare; enhance patient protections and private coverage requirements; lift coverage restrictions on Medicaid and SCHIP; and build on the health insurance program for federal employees. Consistent with the mission of the Legal Solutions in Health Reform project, this article does not endorse a particular policy. Instead of recommending “what,” it explains “how.”. (shrink)

The Affordable Care Act1 promises to improve access to coverage and care for two vulnerable groups: low-income persons who are excluded by a lack of resources and chronically ill and disabled people who are excluded by the dysfunction of our existing insurance and care delivery systems. ACA’s sprawling provisions raise a wealth of implementation challenges that are exacerbated by the compromises required to move reform through Congress. In particular, the compromise between regulatory/public program advocates and advocates for private, market-driven programs (...) requires thoughtful regulatory coordination between public and private health systems. (shrink)

The Affordable Care Act1 promises to improve access to coverage and care for two vulnerable groups: low-income persons who are excluded by a lack of resources and chronically ill and disabled people who are excluded by the dysfunction of our existing insurance and care delivery systems. ACA’s sprawling provisions raise a wealth of implementation challenges that are exacerbated by the compromises required to move reform through Congress. In particular, the compromise between regulatory/public program advocates and advocates for private, market-driven programs (...) requires thoughtful regulatory coordination between public and private health systems. (shrink)

Even when turning its attention to public health topics such as preventive care and workplace wellness, the Affordable Care Act law embodies a highly individualistic paradigm of health. The provisions of the law implicitly assign the primary responsibility for prevention to individuals, who should be urged to make more responsible and healthier choices about what they consume and how they live. Relatively little in the law reflects the “population perspective” set forth in public health scholarship that focuses on environmental and (...) social determinants of health. This article explores the cultural and economic factors that led Congress to embrace a highly individualist conception of public health, and it suggests how public health advocates and legal scholars might seek to reframe the public discourse surrounding preventive health issues. (shrink)

Proponents of care ethics tend to reject the ideals of historical republicanism and the enlightenment because they do not take into account the centrality of the roles played by carers or caregivers in society. Furthermore this is irremediable because of enlightenment’s prizing of reason over and above emotions and of independence over relationships. In this paper I argue that such a wholesale rejection is misguided because it is based on a fundamental misunderstanding of the ideals of enlightenment and republicanism which (...) did value both the emotions and relationships. I focus on the example of one feminist republican writer of the eighteenth century, Sophie de Grouchy, and argue that her response to Adam Smith’s Theory of Moral Sentiments, the Letters on Sympathy provide a model for a feminist republican social reform. I discuss de Grouchy’s arguments on the relationship between sympathy and morality, and on the kind of social and political reforms which are needed in order to ensure that sympathy can operate freely as a regulator of human interactions. I also show how her claim that sympathy originates in the first human relationships, namely between a child and the woman who feeds them means that in this republican account, mothering is identified as central to the well-functioning of human society. (shrink)

This paper argues that liberalism provides democracy with the experience of civic reformism. Without it, democracy loses any tie-argumentative or practical-to a coherent design of public policy endeavoring to provide the resources for the realization of democratic citizenship. The case for liberalism rests on an argumentative reconstruction of the function it performs before the rise of a world economic order and, more specifically, in the creation of the welfare state after the Second World War. Accordingly, liberalism defines a reformist political (...) program: it is an emancipatory political project by virtue of its struggle for an egalitarian and universalist extension of citizenship rights. This is but a formulation of the modern idea of citizenship, conceived of as a universalizable contract of rights. At the same time, liberalism embraces a socioeconomic emancipatory project that endeavors to provide the conditions, within the institutional framework of modern societies, for the accomplishment of citizenship rights. (shrink)

The last year, June 1992 through September 1993, has seen a great deal of ferment with respect to access to and financing of health care in the United States. The elections of 1992 portend dramatic changes in the American health care system, and vigorous debate regarding both expansion of access to health care and transformation of the health care financing system is taking place at the federal and the state levels. In fact, however, the time period covered here produced remarkably (...) few changes in the law, particularly at the federal level. The one piece of Medicare and Medicaid legislation passed by Congress in the fall of 1992, H.R. 11, was vetoed by President Bush immediately after the election. The Omnibus Budget Reconciliation Act of 1993 contained a host of minor adjustments to the Medicare and the Medicaid programs, but only the Medicaid asset transfer provisions and extensions to the self-referral provisions of the fraud and abuse laws, discussed below, are of import to us. (shrink)

The last year, June 1992 through September 1993, has seen a great deal of ferment with respect to access to and financing of health care in the United States. The elections of 1992 portend dramatic changes in the American health care system, and vigorous debate regarding both expansion of access to health care and transformation of the health care financing system is taking place at the federal and the state levels. In fact, however, the time period covered here produced remarkably (...) few changes in the law, particularly at the federal level. The one piece of Medicare and Medicaid legislation passed by Congress in the fall of 1992, H.R. 11, was vetoed by President Bush immediately after the election. The Omnibus Budget Reconciliation Act of 1993 contained a host of minor adjustments to the Medicare and the Medicaid programs, but only the Medicaid asset transfer provisions and extensions to the self-referral provisions of the fraud and abuse laws, discussed below, are of import to us. (shrink)

The Employee Retirement Income Security Act of 1974 , a federal law regulating private employer-sponsored employee benefit plans, was primarily designed for pension plans, but has had a profound impact on state health care reform efforts. ERISA's broad preemption language has been judicially interpreted to preclude states from most forms of regulation of employer health plans, including benefit design and incorporating employer expenditure requirements in state health reform financing. But since 1974, Congress has never seriously returned to reexamine several fundamental (...) questions: Should employers be required to offer or contribute to employee health coverage? Should ERISA preempt state efforts to take such actions? Or should ERISA incorporate more comprehensive regulation of health plans in these areas? Although the politics of ERISA preemption have thus far blocked federal reform, while allowing state reform activity to be simultaneously curtailed, new health reform efforts may force Congress to address these questions. (shrink)

For most of the first two decades after the enactment of the Employee Retirement Income Security Act of 1974, health policymakers did not seem to recognize the full impact that ERISA would have on regulation of health insurance and health care coverage. Perhaps the early court decisions in which the courts clarified that states could regulate insurance companies and the products they sold to ERISA plan sponsors gave them false comfort that because Congress appeared to recognize the role of the (...) states in regulating insurance, ERISA might have only a tangential impact on health care reform efforts. (shrink)

The health care industry has moved at a rapid pace away from paper records to an electronic platform across almost all sectors — much of it at the encouragement and insistence of the federal government. Such rapid expansion has increased exponentially the risk to individuals in the privacy of their data and, increasingly, to their physical well-being when medical records are inaccessible through ransomware attacks. Recognizing the unique and critical nature of medical records, the United States Congress established the Health (...) Care Industry Cybersecurity Task Force under the Cybersecurity Information Sharing Act of 2015 for the purpose of reviewing cybersecurity risks within the health care industry and identifying who will lead and coordinate efforts to address such risks among the various agencies. The Task Force has since issued a report setting forth six high-level imperatives that the health care industry needs to achieve in order to combat cybersecurity, and, notably, many of the vulnerabilities plaguing the industry identified in the Report as requiring correction are not necessarily related to specific flaws in the current cybersecurity framework, but rather susceptibilities presented by the infrastructure and associated regulatory regime that has evolved over the last few decades over the health care industry generally. That is, the current health care infrastructure by its nature exacerbates cybersecurity risk. Between a lack of information sharing of industry threats, risks, and mitigations, disparate leadership and governance goals for cybersecurity, the confluence and contradiction of existing federal and state laws, fragmentation in the fee-for-service delivery system, lack of care coordination, and disparate resources across and among sectors, the industry suffers from heightened cyber risk. Solutions that are reactive to problems within the current infrastructure will likely have little long term impact toward reducing cybersecurity vulnerabilities because they do not address the underlying system challenges. All of these confluences causes one to wonder whether if in fact the current health care delivery infrastructure is a contributing factor to the incidents of cybersecurity attacks and the exorbitant costs associated with resolving data breaches, should Congress look not just to curb breach incidents, but to address root cause systematic challenges in the health industry infrastructure that create increased exposure of cybersecurity threats? This article argues that cybersecurity risks will continue to be heightened and more costly to the health care industry as compared to other industries unless and until some general system redesign is achieved that allows for greater sharing of resources among industry participants to ensure the same protections are implemented at all levels of the industry, which can be strengthened through greater interoperability of systems across the health care industry; and increased focus and attention on the importance of cybersecurity issues as a priority among system reforms. (shrink)

As we write this paper in spring 2008, many are hopeful that November’s election will open the door to some form of comprehensive health care reform. In all likelihood, we will elect a president who has campaigned to a greater or lesser extent on promises of improving access to health care, improving quality, and reducing costs. Equally important, it seems likely that the 111th Congress is preparing to undertake meaningful health care reform. And perhaps most important, despite recent attention to (...) energy issues and the economy, opinion polls consistently show that the American public continues to rank health care as one of the two or three most important domestic issues in the fall elections and supports comprehensive health care reform. (shrink)

It should come as no surprise to any observer of health policy debates that the preemption provisions of the Employee Retirement Income Security Act will play a major role in determining the contours of any health reform initiative. For the past few years, many states have been aggressively pursuing health reform experiments, while congressional action has essentially been deadlocked along partisan political lines. Yet after the 2008 election results, there is reason to expect considerable congressional attention to health reform. President (...) Obama has made health reform a priority of his administration, and several members of Congress have long been waiting for an opportunity to pursue health reform legislation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Working on the Clinton Administration's Health Care Reform Task ForceNancy Neveloff Dubler (bio)This narrative is based on my understanding of the elements of the Health Security Act that may have ethical implications. I have reconstructed these elements from my experience on the Health Care Reform Task Force and they are part of the health care plan that the President presented to Congress. (At the time this article went to (...) press, the actual legislation, which should answer my remaining specific questions more clearly, had not yet been released.) I perceive the most important features of the plan to be:• The legislation will create a "right" to health care for all citizens—access to care will be universal;• The plan will involve some form of managed competition in which groups of providers (called Approved or Accredited Health Plans (AHPs)) will offer comparable benefit packages at slightly (or widely) different costs;• The AHPs will negotiate with the Health Alliance (HA) to determine the price that they will charge their consumer-patients;• There will be open enrollment with no barriers to coverage, such as exclusions for pre-existing conditions;• Community rating will be in effect in different localities and enrolled persons in any AHP will pay the same premium;• The coverage for any enrolled person will be portable;• The overall structure will be a cooperative federal/state enterprise in which the states will have quite extensive abilities to fashion variations of the basic plan to meet their particular needs;• Primary care will be encouraged and incentives for physicians to train in primary care specialties provided;• Non-physician providers will be central to the functioning of the health care plans;• Efforts will be made to develop a "person power" pool so that people with an abstract "right" to health care will have real access to providers, in their localities, who can fulfill the promise that the right creates; [End Page 421]• The goal of cost containment will be central to the organization and regulation of the system;• Administrative simplicity and quality protections will be central.Co-chairing the Bioethics Working Group (BWG) of the White House Task Force on Health Care Reform was a unique experience. Approximately 40 Task Force working groups were established by Hillary Rodham Clinton, the President, and the senior Task Force staff. Various members of the President's office and other knowledgeable members of the Executive Branch selected the participants. In our group, appointments were made largely on the recommendations of the co-chairs. The BWG, among the last of the groups formed, carried the official name "The Working Group on the Ethical Foundations of the New System" and was jointly led by me and Marion Gray Secundy, a Professor of Bioethics at Howard University. The fact that the leadership of the Task Force saw fit to establish such a group, thereby confirming that bioethics is a player in the arena of health care policy, was in itself significant and was made no less so by the lack of clarity regarding the group's aims and goals.The working groups of the Task Force were organized into clusters, determined by the relatedness of the somewhat distinct, but always overlapping, content of their investigations. Separate clusters and working groups, for example, looked at mental health, long term care, and the benefit package and coverage for low-income and non-working families. On this last issue there was also a working group that explored health policy initiatives for underserved populations. This multiple focus on related issues proved to be an excellent method for ensuring that the complexity of these topics was sufficiently explored. There was a published schedule for when these groups met together, and members of other groups who had similar or overlapping concerns were invited to attend and to participate.Every week or so, all of the working groups reported to the Task Force leadership, under the direction of Ira Magaziner, in a process called a "tollgate." Prior to the tollgate, the working groups were required to submit formal written analyses of the problems they had most recently been considering. Copies of these documents were placed in a special room so that those who were interested could review... (shrink)

In 1974, the United States Congress asked a question prompting a national conversation about ethics: which ethical principles should govern research involving human participants? To embark on an answer, Congress passed the National Research Act, and charged this task to the newly established National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Commission’s mandate was modest however, the results were anything but. The outcome was The Belmont Report: a trio of principles - respect for persons, (...) beneficence, and justice - serving as an ethical compass for scientists, researchers, and institutional review boards (IRBs). Almost 50 years later, the utility, legacy, and ingenuity of The Belmont Report continues to be both admired and challenged. Critics argue that Belmont is not fit for the 21st century, while supporters praise Belmont for its enduring wisdom. The goal of this paper is to equip IRB practitioners with the tools necessary to maximally interpret The Belmont Report and meaningfully engage in ethical analysis that reconsiders outmoded legacy thinking and fixed decision-making. Through historical and contextual reflection, this paper describes how IRB practitioners can contemporize review of ethical human research using their moral imagination – a skill found at the intersection of creativity, deliberation, and empathy. (shrink)

Part of the bafflement over expressions like “contemporary” and “postmodern” in philosophy can be traced to a flood of nineteenth-century historians of philosophy who dubbed the so-called “post-medieval” era from Bacon and Descartes to Mill and Nietzsche the “Philosophie der Neuzeit,” “L’époque moderne,” and “modern philosophy.” Even the philosophers mentioned suffice to indicate that these labels are often only placeholders for views of thinkers linked by little more than a birth after the onset of the Reformation and a death (...) before the Curies’ discovery of polonium. Nevertheless, philosophers in the twentieth century and their historians were faced with the dilemma of either subsuming their work under this broadly conceived moniker, thereby signaling nolens volens a lack of significant innovation, or coming up with some appropriately distinctive term. (shrink)

Policy officials often assert that the U.S. has the best health care system in the world, but a recent scorecard on U.S. health system performance finds that the U.S. achieves a score of only 65 out of a possible 100 points on key indicators of performance in five key domains: healthy lives, access, quality, equity, and efficiency, where 100 represents the best achieved performance in other countries or within the U.S. The U.S. should aim higher by adopting a set of (...) policies that will extend affordable health insurance to all; align financial incentives for health care providers to enhance value and achieve savings; organize the health care system around the patient to ensure that care is accessible and coordinated; meet and raise benchmarks for high-quality, efficient care; and ensure accountable national leadership and public-private collaboration. The incoming president and Congress should aspire to have the best health system in the world — not just assert it — and can do so by learning from examples of excellence within the U.S. and abroad. (shrink)

The recent withdrawals of Vioxx, Celebrex, and other drugs from the market have spurred high-profile hearings in Congress and increased concern over the state of drug regulation in consumer protection and academic circles. This renewed focus on national drug safety has translated ineluctably into new legislation designed to mitigate that outcry. The most notable example, the passage of the Food and Drug Administration Amendments Act this past September, is at least partly intended as a response to an apparent lack of (...) public confidence in existing drug safety practices.Of the many provisions in the FDAAA, perhaps none carries greater implications for drug safety than the reauthorized Prescription Drug User Fee Act. Now in its fourth iteration, the newest PDUFA differs in important respects from the statute it supersedes. (shrink)

Not since the civil rights era has enacted national legislation been fought so fiercely as the Patient Protection and Affordable Care Act. Political, ideological, and social forces have mobilized to undermine the ACA at numerous fronts, including the Supreme Court, Congress, state governments, and the court of public opinion. The ACA has survived a constitutional challenge, a presidential re‐election, numerous repeal votes in the House, and avowedly obstreperous state regulators. But it has not yet run the full gauntlet of lethal (...) strategies. The latest line of attack is a collection of orchestrated lawsuits seeking to keep the federal exchange from paying any premium tax subsidies.What if the challengers eventually prevail? What would happen then? (shrink)

Sweeping changes in technology followed by political, social and economic transformation are modifying the expectations from education. There is urgent need for reforms in the aim, content and method of education systems. Evidence is gathered to justify this need and suggest a process that will lead to the desired reform. We argue that character education is a requirement in order to ensure that changes move in the direction envisaged. Empowerment of the parties involved will change the mood of silence and (...) transform the agents into active participants in change. (shrink)

The Next Step in Religion: An Essay toward the Coming Renaissance is a classic religious essay by Roy Wood Sellars that examines christianity and humanism includes the following excerpt: More than people are consciously aware, a new view of the universe and of man's place in it is forming. It is forming in the laboratories of scientists, the studies of thinkers, the congresses of social workers, the assemblies of reformers, the studios of artists and, even more quietly, in the circles (...) of many homes. This new view is growing beneath the old as a bud grows beneath its covering, and is slowly pushing it aside. (shrink)

From a giant of health care policy, an engaging and enlightening account of why American health care is so expensive -- and why it doesn't have to be. Uwe Reinhardt was a towering figure and moral conscience of health care policy in the United States and beyond. Famously bipartisan, he advised presidents and Congress on health reform and originated central features of the Affordable Care Act. In Priced Out, Reinhardt offers an engaging and enlightening account of today's U.S. health care (...) system, explaining why it costs so much more and delivers so much less than the systems of every other advanced country, why this situation is morally indefensible, and how we might improve it. The problem, Reinhardt says, is not one of economics but of social ethics. There is no American political consensus on a fundamental question other countries settled long ago: to what extent should we be our brothers' and sisters' keepers when it comes to health care? Drawing on the best evidence, he guides readers through the chaotic, secretive, and inefficient way America finances health care, and he offers a penetrating ethical analysis of recent reform proposals. At this point, he argues, the United States appears to have three stark choices: the government can make the rich help pay for the health care of the poor, ration care by income, or control costs. Reinhardt proposes an alternative path: that by age 26 all Americans must choose either to join an insurance arrangement with community-rated premiums, or take a chance on being uninsured or relying on a health insurance market that charges premiums based on health status. An incisive look at the American health care system, Priced Out dispels the confusion, ignorance, myths, and misinformation that hinder effective reform. (shrink)

Institutional Review Boards and their federal overseers protect human subjects, but this vital work is often dysfunctional despite their conscientious efforts. A cardinal, but unrecognized, explanation is that IRBs are performing a specific function – the management of risk – using a flawed theoretical and practical approach. At the time of the IRB system’s creation, risk management theory emphasized the suppression of risk. Since then, scholars of governance, studying the experience of business and government, have learned that we must distinguish (...) pure from opportunity risks. Pure risks should be suppressed. Some opportunity risks, in contrast, must be accepted if the institution is to meet its goals. Contemporary theory shows how institutions may make these decisions wisely. It also shows how a sound organizational understanding of risk, a proper locus of responsibility, and appropriate institutional oversight all contribute to effective risk management. We can apply this general theory, developed in other contexts, to the problems of the IRB system. Doing so provides a unifying explanation for IRBs’ disparate dysfunctions by spotlighting five related deficiencies in IRB theory and structure. These deficiencies are inability to focus on greater risks, loss of balanced theory, inaccessibility to guidance from senior leadership, unbalanced federal oversight, and inflexibility. These flaws are deeply rooted in the system, and superficial reform cannot resolve them. Congress should overhaul the system to meet contemporary standards of risk management; this would benefit subjects, scientists, and the public that needs the fruits of research. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:President’s Council on BioethicsEdmund D. Pellegrino (bio) and F. Daniel Davis (bio)Approximately two weeks before what was to have been its final meeting, the White House dissolved the President’s Council on Bioethics by terminating the appointments of its 18 members. The letters of dismissal, dated 10 June 2009, informed the members that their service on the Council would end with the close of business the next day.The Council’s term (...) was set to expire on 30 September 2009. After President Obama’s election in November and during the transition, we were advised to proceed on the assumption that the Council would be permitted to cease on that date. Reasons for the abrupt move to disband the Council are unknown. We have accepted the fact that we Council members served at the pleasure of the President and that he simply exercised his rightful prerogative. No explanation is therefore required.Some observers have speculated that the action was retaliatory. They related to the fact that several members of the Council disagreed with the President’s stem cell policy in a signed statement published in the Hastings Center’s Bioethics Forum. Others have speculated that the move was pre-emptive. At its final meeting, scheduled for 25–26 June, the Council was set to sign-off on two of its final publications. One was a comprehensive report on the ethics of organ transplantation, and the other a white paper entitled Health Care and the Common Good. The aim was immediately to release the latter as a contribution to the intensifying debate about health care reform. Health Care and the Common Good could well have aided rather than impeded the President’s drive to better control health care costs and achieve universal coverage. The Council report attempted to ground both goals in the ethical framework of, as the title indicates, the common good of all Americans.In his letter terminating the members’ appointments, Assistant to the President for Presidential Personnel Don Gips said that the President “recognizes the values of having a commission of experts in bioethical issues to provide objective and non-ideological bioethics advice to his administration.” Gips went on to say that the President is “currently rethinking the purposes and goals of such a bioethics commission, and is carefully considering a revitalized mission and mandate.” And, [End Page 309] responding to media enquiries, White House press officer Reid Cherlin explained that the President’s Council was terminated because it was a “philosophically leaning advisory group” and, according to a New York Times account by Nicholas Wade, “because it favored discussion over developing a shared consensus.” As for the ultimate outcome of the President’s “rethinking,” Cherlin indicated that President Obama will appoint a new commission with the mandate of offering “practical policy options” in bioethics.In the light of our experiences with the Council, we leave it with hopes that certain questions of national importance will be addressed. In light of the nature of federal advisory commissions, what is or are the proper roles of a national bioethics commission? If the aim is to provide advice and counsel to the President or, perhaps to the U. S. Congress, is that advice best rendered as a group consensus or as an in-depth exploration of the inevitably conflicting ethical perspectives on a given issue? How should such a commission be constituted—with what sorts of individuals? And what is the nature of the expertise that they individually and collectively bring to the commission’s functions? If the commission is to promote public debate and discussion, how exactly should it go about that task? And how is the efficacy of a commission to be assessed? Such questions inevitably lead us deep into contested territory, as the experience of this Council has shown: into the intersections of politics, religion, and science and into the relations between practice and theory—between policy and what some seem to deride as “philosophy.” Indeed, policy without an underlying philosophy is an edifice without a foundation; philosophy without policy is a foundation without an edifice.At the last meeting of the Council in March 2009, we launched a discussion of these questions with the... (shrink)

No provision of the Patient Protection and Affordable Care Act has proven to be more contentious than the so-called “individual mandate.” Starting in 2014, the mandate will impose a penalty on non-exempt individuals who lack health insurance. According to Congress, the mandate is essential to ensuring near universal coverage. Without it, PPACA’s insurance reforms will lead healthy individuals to delay purchasing health insurance until they require medical care, resulting in risk pools with a disproportionate share of high-risk people. The price (...) of insurance will then climb, causing more and more not-so-sick people to forego health insurance. The resulting “death spiral” will make insurance unaffordable to many more Americans. (shrink)

The call for the emancipation of minds, a renunciation of stereotypes and routines, and an honest and critical analysis of the processes taking place in our society permeates all the documents of the Twenty-seventh Congress, the subsequent plenums of the Central Committee of the CPSU, and the speeches of the leaders of our Party and government. Today the Party is insistently demanding of philosophers and social scientists mat they step up their creative pursuit of theoretical developments and practical recommendations to (...) expand democratization and openness, and to reform and improve the mechanism of socialist self-government. (shrink)

Cette édition numérique a été réalisée à partir d'un support physique, parfois ancien, conservé au sein du dépôt légal de la Bibliothèque nationale de France, conformément à la loi n° 2012-287 du 1er mars 2012 relative à l'exploitation des Livres indisponibles du XXe siècle. Pages de début Les auteurs Présentation La science en mutation Les savoirs en question, réflexions après coups Première partie : La science : idéal et réalités La science : ambiguïtés contemporaines La vocation manipulatoire de la science (...) Ça marche, enquête chez les branches Deuxième partie : Les mathématiques, aujourd'hui Analyse des épisodes d'une controverse : la réforme des mathématiques des années soixante L'enseignement des mathématiques : savoirs ou savoir-faire? Mathématiques et métapsychologie Troisième partie : Le sujet du savoir Sujet/objet Rencontre avec Jeanne Favret-Saada A propos du livre de Jeanne Favret-SaadaDiscours de la méthode corporelle Postface Pages de fin. (shrink)

The debate over environmental, health, and safety regulation has reached a new crescendo in the 104th Congress. So impassioned is the debate on occasion, and so high the feelings, that even the tools of regulatory analysis have become part of the combat.To some, the term cost-benefit analysis, for example, is virtually a swearword, a nefarious tool used by big business to undermine regulations aimed at benefiting the people at large. To others, it is the mechanism for achieving more effective regulation (...) at less cost.This new book on the subject of reforming regulation is aimed at increasing the light and turning down the heat. It consists of an introduction and nine chapters written by scientists, public policy analysts, and economists on various aspects of regulation and regulatory analysis.The book advances the latest knowledge and evidence on risk analysis, cost-benefit analysis, and related techniques for improving regulation--all based on experience and data accumulated over the quarter century since regulation in the areas of environment, health, and safety became a major player on the governmental stage. The strengths and limitations of those analytical tools are an important part of the portrait that is painted, but a common thesis is that, properly used, the tools can be helpful in getting better regulatory results. (shrink)

Due to society's need to control health care costs and to the failure of legislated health care reform, managed care is expanding at a rapid rate and will soon be the predominate form of health care delivery. Plans by Congress to bring Medicare and Medicaid under managed care will further consolidate this trend. Barring some legislative fiat, managed care is here to stay.The term managed care describes a diverse set of organizational forms. Wide variations in approach, financing, physician involvement, and (...) philosophy exist among the different types of managed care organizations. While many articles on the ethics of managed care acknowledge this variety, most analyses focus on the for-profit entities, paying less attention to the ethical distinctions among the different forms of managed care. This paper discusses the key distinctions among MCO types, in particular the difference between for-profit and non-profit plans; the relationship of the physician to the MCO; the incentives used to control costs; the incentives that improve patient care; and the organizational features that nurture the principled practice of medicine. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:THE DOMINICAN SCHOOL OF SALAMANCA AND THE SPANISH CONQUEST OF AMERICA: SOME BIBLIOGRAPHICAL NOTES THOMAS F. O'MEARA. O.P. University of Notre Dame Notre Dame, Indiana SALAMANCA, northwest of Madrid and Avila and not far from Spain's border with Portugal, preserves the atmosphere of a medieval, Renaissance, and Baroque university even as it develops the schools and clinics of a contemporary center of studies. There are associations with Teresa of (...) Avila, who spent the night there just after her reform was approved by Rome, with the young Cervantes, with Luis de Leon and Ignatius Loyola, and with John of the Cross, who was a student there. A bridge from the time of Trajan spans the river Tormes, and the Romanesque cathedral still reserves a chapel for the Mozarabic rite. The University of Salamanca The city brings to mind sixteenth century Dominicans like Francisco de Vitoria, often called the founder of international law, and Domingo Bafiez, confessor to Teresa of Avila. The Order of Friars Preachers, however, came to Salamanca in 1222 at the same time that Dominic's missions were taking root in·Paris and Bologna; the friars founded a priory and soon a school under the patronage of St. Stephen (San Esteban). The " Dominican School of Salamanca " means formally the line of great theologians reaching from Diego de Deza at the end of the fifteenth century to Tomas de Lemos, a main protagonist in Rome in 1607 in the controversy over grace entitled De Auxiliis. Today, after seven and a half centuries of existence, the Salamancan SSS 556 THOMAS F. o'MEARA, O.P. Dominicans remain a vital community, active m teaching, research and publishing. My attention was directed to the Dominicans at Salamanca by two volumes of essays reporting on congresses concerning the "Dominicans and the Discovery of the New World." My interest was not church history but the history of theologies of how grace might exist outside of explicit faith and sacramental baptism. The following report is a bibliographical survey of recent research on a theological era and school. Focusing on the thought of the theologians stimulated by the experiences of the missionaries in the Indies, it treats the Dominicans during the first decades after the voyages of Columbus. In the 1480s, as it entered its golden age, the University of Salamanca had a hundred professors and almost 7000 students. University records begin late, but they show that in 1546/47, one hundred thirty-four Dominicans were studying at the university, and in 1598/99, eighty. J. L. Espinel has written. a historical guide to the Dominican buildings and institutions.1 The great period of the Dominican school at the University began with Diego de Deza ( 1480-1486), professor and archbishop of Seville, and Matias de Paz (1518-1519), a professor of Scripture. Francisco de Vitoria (1526-1546) and Domingo de Soto (15321549 ) were its most gifted thinkers, but the school's achievements continued with Melchior Cano (1546-1552), Juan de la Pefia (1561-1565) and Domingo Banez (1581-1604). These t San Esteban de Salamanca, Historia y Gufa, Siglos, XIII-XX (Salamanca: Editorial San Esteban, 1978); see also R. Hernandez, "Convento y estudio de San Esteban," La Universidad de Salamanca (Salamanca: Universidad, 1989), pp. 369ff.; A. Martin Melquiades, "La Escuela de teologia de Salamanca," Atti del Congresso internazionale, Tommaso d'Aquino nel suo settimo centenario, Tommaso d'Aquino nella storia del pensiero, 1 :2 (Naples: Edizione Domenicane Italiane, 1975), pp. 242ff. A Salamancan Dominican of the 1930s, Vicente Beltran de Heredia, pioneered research in the history of the university and in the writings of the Dominican speculative masters. His writings can be found in past issues of Ciencia Tomista (CT), and some of his books and several recent collections of his most important essays are available from Editorial San Esteban. Similarly initial research in the United States can be found in the writings of Lewis Hanke. SALAMANCA AND THE SPANISH CONQUEST 557 are joined by lesser figures like Pedro de Sotomayor (15601564 ), Mancia de Corpus Christi (1564-1576), and Bartolome de Medina (1576-1581). The occupants of the chair in theology of the liturgical hour of prime from Vitoria in 1526 to Bafiez's... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Managed Health Care: New Ethical Issues for All*Martina Darragh (bio) and Pat Milmoe McCarrick (bio)Changes in the way that health care is perceived, delivered, and financed have occurred rapidly in a relatively short time span. The 50-year period since World War II encompasses enormous growth in medical technology, soaring health care costs, and significant fragmentation of the two-party patient- physician relationship. This relationship first grew to include the third-party (...) payer, the health insurance industry, and now “with great speed and relatively little public awareness, a significant change has occurred in the way some decisions are made about a patient’s medical care” (III, Institute of Medicine 1989).The new means of providing health care bring an increasing number of parties into clinical decision-making processes. With this change, ethical issues that once concerned only health care professionals, the physician or the nurse, have expanded to include the patient and the groups who “manage” care—e.g., health maintenance organizations (HMOs), preferred provider organizations (PPOs), point of service groups (POSs), independent practice associations (IPAs), insurance reviewers, hospital administrators, institutional managers, and, the most recent players, purchasers of group health care who base their decisions on competitive pricing.The term “managed care” refers to a variety of continually adapting and developing arrangements that involve four groups. These groups, which have been labeled by the world of business, not health, are the “consumer” (once the patient), the “provider” (the physician and other health care professionals), the “insurer” (the reimburser for any care), and the “purchaser of care” or the primary buyer of health services (the large employer organization). Capitation is a common way to pay for health services in managed care systems. A certain dollar amount is negotiated for health services for a specified number of patients whether the care is delivered or not; the provider shares with the [End Page 189] insurer any financial risk for the actual cost of care (III, Centers for Disease Control 1995).When the Clinton administration’s health care reform movement failed to gain support in the U.S. Congress, the use of managed care to control rising health care costs accelerated. The literature on managed care and its effect on the patient-physician relationship reflects this shift. During the era of health care reform, “debate centered on how managed care could control costs, on the use of technology and patient satisfaction, [and] on access and barriers to care” (IV, Emanuel and Dubler 1995). When managed care organizations began contracting with physicians to provide health care services subject to the plans’ provisions, these plans became agents in clinical decision making on a wide-spread basis. HMO enrollment grew to 51 million persons by 1994 (III, Centers for Disease Control 1995). This “corporatization” of health care has sparked a plethora of articles about the effects of the marketplace on the physician’s ability to do what is best for the patient, and on the patient’s ability to trust the physician to do so.Many authors make it clear that managed care itself is not the problem, but rather the development of for-profit managed care plans by “corporate conglomerates with billions of dollars in assets that compensate their executives as grandly as basketball players” (V, Kassirer 1995) “in a marketplace that is largely unregulated” (I, Zoloth-Dorfman and Rubin 1995). “Some, mostly older plans that were created when cost containment was an unexpected benefit rather than their central purpose, deliver high-quality care economically. Unfortunately, others cut costs by recruiting the healthiest patients, excluding the sickest, rationing care by making it inconvenient to obtain, and denying care by a variety of mechanisms” (V, Kassirer 1995).These cost-containment features now play an intimate role in clinical practice. When a managed care plan contracts with a physician, the doctor becomes a “double agent” with contractual obligations to the plan to provide a preset amount of services and professional responsibilities to each patient to authorize necessary treatment (V, Angell 1993). This duality can undermine the physician’s fiduciary responsibility to the patient wherein the physician “has power over the affairs of [the patient]...and is required by law to act on that person’s... (shrink)

The dominant moral philosophy of nineteenth-century Britain was utilitarianism, beginning with Bentham and ending with Sidgwick. Though once overshadowed by his immediate predecessors in that tradition, Sidgwick is now regarded as a figure of great importance in the history of moral philosophy. Indeed his masterpiece, The Methods of Ethics, has been described by John Rawls as the 'most philosophically profound' of the classical utilitarian works. In this volume a distinguished group of philosophers reassesses the full range of Sidgwick's work, not (...) simply his ethical theory, but also his contributions as a historian of philosophy, a political theorist, and a reformer. (shrink)

Signs and States, programme financé par l'ERG (European Research Council), a pour but d'explorer la sémiologie de l'Etat du XIIIe siècle au milieu du XVIIe siècle. Textes, performances, images, liturgies, sons et musiques, architectures, structures spatiales, tout ce qui contribue à la communication des sociétés politiques, tout ce qu'exprime l'idéel des individus et leur imaginaire, est ici passé au crible dans trois séries de rencontres dont les actes ont été rassemblés dans une collection, Le pouvoir symbolique en Occident (1300-1640). Ces (...) volumes, adoptant une perspective pluridisciplinaire et comparative dans une visée de long terme, combinent études de cas, analyses conceptuelles et réflexions plus théoriques. Et les réponses à ce questionnaire, issu d'une réflexion sur une histoire culturelle poursuivie sur plus de cinq siècles, remettent en cause une histoire de l'Occident latin où l'on opposerait Eglise et Etat : la mutation culturelle engendrée par la réforme grégorienne qui, tout en assurant d'abord le triomphe de la papauté, a donné à l'Etat moderne les moyens d'assurer sa propre légitimité en créant les conditions d'une révolution du système de communication. Elle engendre un partage du pouvoir symbolique et des processus de légitimation avec l'Etat : la capacité de ce dernier à se légitimer par le consentement de la société politique en dehors de la contingence religieuse est une spécificité de l'Occident latin, clé de l'essor des Etats modernes européens. (shrink)

In September 1994, theNew York Timescarried a front page article declaring healthcare reform dead in Congress. The obituary on healthcare followed a Congressional decision not to pursue the issue further in 1994. Although Congress and the President will likely revisit healthcare reform during 1995, the choices may be between various incremental steps, rather than substantive changes to bring about universal coverage.

The socio-economic “pro-democracy” revolutions which are currently sweeping the Soviet Union and Eastern Europe in the name of glasnost and perestroika have virtually stunned all but the best informed in the Western World. The demand for reform throughout the so-called “Soviet block,” and the concomitant impatience with the progress of these changes in the economic and basic social fabric of these societies, have come to exhibit an urgency which few observers, if any, had been able to forecast a few short (...) years ago. The declarations by some members of the U.S. Congress that these changes are indicative of the fact that the cold war has been won by the West, and that we are now witnessing the precipitous collapse of Marxist ideology, together with the widespread sentiment that there is “no going back” to the repressive Leninist-inspired regimes of Stalin, Khruschev, and Brezhniev are all synergistic to the creation of a sentiment of optimism that indeed we have turned the corner in East-West relations. To a world which has lived under the long night of thermonuclear extinction for over four decades, the feeling accompanying the prospect of a possible end to the nightmare of Armageddon further enhances the euphoric sentiment. (shrink)

Historically, the preconditions for the emergence of bioethics in China. were political reforms and their applications. The Hanzhong Euthanasia Case and the publication of Qiu Ren-zong's academic work Bioethics played a significant role in the development of bioethics in China. Other contributory factors include the establishment of the Chinese Society of Medical Ethics/Chinese Medical Association (C.M.A), the publication of the Journal of Chinese Medical Ethics, and the teaching and education of bioethics in China. Major achievements of bioethics in China include (...) the establishment of ethics committee and ethics review system, active international communication and cooperation among the academic circles, and the successful management of the 8th World Congress of Bioethics in Beijing in 2006. Chinese bioethics focus on native Chinese realities and conditions, absorb the international research achievements in relevant fields, and combine international ideas with traditional Chinese doctrines. Admittedly, there are still some aspects to be improved, yet bioethics has attracted a lot of attention from the core leadership in China and has gained sound financial support, which augers well for its further development. This article also briefly introduces the development of bioethics in Hong Kong and Taiwan, China. (shrink)

The Second World War and its associated political events of a national and global scale brought new circumstances, which was considerably influenced the development processes of Tehran. During World War II, Iran hoped that Washington would keep Britain and the Soviet Union from seizing control of the country’s oil fields. In 1951 and 1952 Truman worked with Iranian Prime Minister, though unsuccessfully, to regain some of those lost oil rights for Iran. By the late 1950s and President Kennedy’s presidency, he (...) used aid as leverage for social reform. During the early years of 1960s, the Kennedy Administration was urging its allies in the third world to carry out necessary reforms in order to prevent popular discontent and enhance the dominant ideology of ‘modernism’. In 1968, a major piece of legislation, the Urban Development and Renewal Act, enabled the municipality to implement Tehran’s Comprehensive Plan (TCP 1968), which integrated all the elements of a 1960s’ American city such as the separation of functions, highways, suburbs, shopping centers and housing area. The export of these American cities principles can only be understood from the background of the Cold War period, in which the east and west were both competing for cultural colonization of Middle Eastern strategically important cities like Tehran. During this period, the new developments supported by the oil boom of 1970s, were built in different forms to constitute an expanding metropolis. In 1974, the second “International Congress of Architecture” with the theme of “Toward a Quality of Life” held at Persepolis and brought together all leading world architects and planners to review Iran’s progress in its professional response to the challenges posed by increasing oil revenues. This research aims to represent the export of planning as a political means of cultural colonization of the Third World during the cold war period. (shrink)

Since its enactment, the Affordable Care Act has faced numerous legal challenges. Many of these lawsuits have focused on implementation of the law and the limits of executive power. Opponents challenged the ACA under the Obama Administration while supporters have turned to the courts to prevent the Trump Administration from undermining the law. In the meantime, Congress remains gridlocked over the ACA and many other critical health policy issues, leaving the executive branch to adopt its preferred policy approach and ultimately (...) leading to lawsuits. This article briefly discusses the history of litigation over the ACA and some reasons why this litigation has been so enduring. The article then identifies other areas of health policy that are or could be future targets for litigation. Finally, the article comments on the potential impact of the courts on future health reform efforts. (shrink)

Due to society's need to control health care costs and to the failure of legislated health care reform, managed care is expanding at a rapid rate and will soon be the predominate form of health care delivery. Plans by Congress to bring Medicare and Medicaid under managed care will further consolidate this trend. Barring some legislative fiat, managed care is here to stay. The term managed care describes a diverse set of organizational forms. Wide variations in approach, financing, physician involvement, (...) and philosophy exist among the different types of managed care organizations. While many articles on the ethics of managed care acknowledge this variety, most analyses focus on the for-profit entities, paying less attention to the ethical distinctions among the different forms of managed care. This paper discusses the key distinctions among MCO types, in particular the difference between for-profit and non-profit plans; the relationship of the physician to the MCO; the incentives used to control costs; the incentives that improve patient care; and the organizational features that nurture the principled practice of medicine. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Patient Self-Determination ActElizabeth Leibold McCloskey (bio)What are the ethics of extending the length of life? We know that we cannot artificially end life (Thou Shalt not Kill), but how about artificially extending life? Is that always good, sometimes good?... In ethics, is keeping people alive the highest good? Should our priority be to keep people breathing?... What does basic religious ethics say about this?(John C. Danforth, letter to (...) the author, 19 August 1989)The Patient Self-Determination Act, signed into law as part of the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) last November, marks the first time that Congress has passed legislation concerning the ethics of life-sustaining medical treatment. The bill was spearheaded by Senator John C. Danforth (RMO), who has a special interest in this area. An Episcopal priest, Danforth was formerly an assistant chaplain at New York's Memorial Sloan-Kettering Cancer Center and now sits as a senior member of the Senate Finance Committee, which oversees Medicare and Medicaid. Although Senator Danforth's legislative initiative was not a result of the Cruzan case, it was in his state of Missouri that the U.S. Supreme Court case involving removal of Nancy Cruzan's feeding tube arose (Cruzan v. Director of Missouri Department of Health, U.S. Supreme Court, 58 LW 4916, 26 June 1990). From his unique vantage point, he felt it was time to craft a legislative response to some of the difficult issues surrounding prolongation of life.The short answer to Senator Danforth's questions about when to artificially extend life is simple enough: people must be free to determine that for themselves. Common law and common sense dictate such a conclusion; living will and health care proxy statutes, enacted in almost every state, codify that right. The Catholic moral tradition teaches that one is not morally obligated to use extraordinary means to prolong life, a tradition shared both by the mainline Protestant and the reform and conservative Jewish community. Yet most people are unaware of their fundamental legal right to make such decisions, and as court cases from Quinlan (In re Quinlin, 137 N.J. Super. 227, 1975) to Cruzan demonstrate, few know [End Page 163] how to make arrangements for this right to be exercised if they become incapacitated.Meanwhile, health care practices are often driven by a denial of death. When Senator Danforth and Senator Daniel Patrick Moynihan (D-NY) introduced the bill on October 17, 1989, Senator Danforth said:More and more it is arguable that we play God by subjecting people to unwanted and sometimes unnecessary treatment, treatment that unnaturally prolongs the dying process. Our health care system has become obsessed with extending life, at times neglecting the caring component of medicine and trampling on the rights of patients.(Congressional Record 1989, 135:5.13566)The American Hospital Association estimates that 70 percent of deaths now occur after a determination to withhold or withdraw medical treatment. Many of those decisions are made without the benefit of an incapacitated patient's views, yet a Harvard study revealed that 95 percent of the population would like to prepare in advance for such decisions. Only 4 percent of hospitals have a systematic method of asking patients if they have an advance directive. Family members confront painful choices in the face of uncertainty about their loved one's wishes and it can be even more painful when a family knows the patient's desires but providers and the courts act otherwise because clear evidence is lacking.The Patient Self-Determination Act is rooted in the belief that people should be given information that enables them to specify the extent of medical treatment they wish to receive should they become incapacitated. The public should be educated about applicable state laws that protect the individual's right to make such choices through the use of an advance directive.The Act moves toward that goal by promoting knowledge of state laws. It requires every hospital, nursing home, home health agency, hospice, and health maintenance organization that participates in Medicaid or Medicare to routinely give all adult patients information about advance directives. Patients will also be given information on the... (shrink)

Logical positivism had an important impact on the Danish intellectual climate before World War Two. During the thirties close relations were established between members of the Vienna Circle and philosophers and scientists in Copenhagen. This influence not only affected Danish philosophy and science; it also impinged on the cultural avant-garde and via them on the public debate concerning social and political reforms. Hand in hand with the positivistic ideas you find functionalism emerging as a new heretical language in art, architecture, (...) and design. Not surprisingly, you may say, since the logical positivists’ wishes of stripping philosophy of metaphysics is spiritually similar to the functionalists’ desire to get rid of symbols and ornaments. One event more than anything confirmed the connection between the Vienna Circle, Denmark, and the rest of the Nordic countries. For a short while Copenhagen became the centre for the Circle’s activities when in 1936 the 2nd Inter national Congress for the Unity of Science was held there between June 21 and 26. A photograph, taken during the conference, shows many of the participants sitting in the hall of Carlsberg’s honorary mansion where Niels Bohr was living at the time. Among the audience you find Otto Neurath , Carl Gustav Hempel and Karl Popper , but also some of the more prominent Danish scientists and scholars whose world views were congenial with the logical positivists. (shrink)