{"title":"Banishing \"Stakeholders\".","authors":"J. Sharfstein","doi":"10.1111/1468-0009.12208","DOIUrl":"https://doi.org/10.1111/1468-0009.12208","url":null,"abstract":"","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"16 1","pages":"476-9"},"PeriodicalIF":0.0,"publicationDate":"2016-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90454127","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A significant social innovation after the Civil War was the establishment of schools and colleges to educate the freed, largely illiterate, black former slaves. The new colleges included 7 medical schools. Only two of them, Howard University College of Medicine in Washington, DC, and Meharry Medical College in Nashville, survived Abraham Flexner’s 1910 report documenting the poor educational standards at most medical schools in the United States and Canada. A century after Flexner’s findings influenced changes that made the American system of health professions education among the best in the world, changes are again needed as we educate and prepare health professionals for the 21st century. These changes include programs to increase racial, ethnic, and socioeconomic diversity among the nation’s health professionals. Throughout the 20th century, black Americans and their allies fought to eliminate segregation, discrimination, and bias in the nation’s educational system. The most visible victory was the 1954 US Supreme Court’s ruling in the case Brown v Board of Education. The Court stated that “separate but equal” educational systems were inherently unequal and, thus, unconstitutional. Since then, many Americans have worked to eliminate vestiges of segregation and bias in our nation. These efforts have had a mixed record of success and failure. Of the nation’s 4,000 colleges and universities, 109 are predominantly black, including 4 of the nation’s 142 medical schools. Does the continued existence of such institutions contradict the goal of an egalitarian, diverse society? Leaders of historically black colleges and universities explain that their purpose is not to perpetuate segregation but, rather, to broaden the opportunities for black students and students from low-income families of every race and ethnicity to be educated in an environment where they
{"title":"Diversity and Higher Education for the Health Care Professions.","authors":"L. Sullivan","doi":"10.1111/1468-0009.12203","DOIUrl":"https://doi.org/10.1111/1468-0009.12203","url":null,"abstract":"A significant social innovation after the Civil War was the establishment of schools and colleges to educate the freed, largely illiterate, black former slaves. The new colleges included 7 medical schools. Only two of them, Howard University College of Medicine in Washington, DC, and Meharry Medical College in Nashville, survived Abraham Flexner’s 1910 report documenting the poor educational standards at most medical schools in the United States and Canada. A century after Flexner’s findings influenced changes that made the American system of health professions education among the best in the world, changes are again needed as we educate and prepare health professionals for the 21st century. These changes include programs to increase racial, ethnic, and socioeconomic diversity among the nation’s health professionals. Throughout the 20th century, black Americans and their allies fought to eliminate segregation, discrimination, and bias in the nation’s educational system. The most visible victory was the 1954 US Supreme Court’s ruling in the case Brown v Board of Education. The Court stated that “separate but equal” educational systems were inherently unequal and, thus, unconstitutional. Since then, many Americans have worked to eliminate vestiges of segregation and bias in our nation. These efforts have had a mixed record of success and failure. Of the nation’s 4,000 colleges and universities, 109 are predominantly black, including 4 of the nation’s 142 medical schools. Does the continued existence of such institutions contradict the goal of an egalitarian, diverse society? Leaders of historically black colleges and universities explain that their purpose is not to perpetuate segregation but, rather, to broaden the opportunities for black students and students from low-income families of every race and ethnicity to be educated in an environment where they","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"74 1","pages":"448-51"},"PeriodicalIF":0.0,"publicationDate":"2016-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74155325","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
When the US Food and Drug Administration (FDA) first approved the da Vinci surgical robot for clinical use in 2000, many people assumed that robotic surgery would have as much effect on improving patient outcomes as had minimally invasive,orlaparoscopic,surgery.Adecadeafteritsintroduction,laparoscopic surgery and the smaller incisions it uses produced clear evidence that patients generally did better—faster recoveries, shorter hospital stays, less bleeding, and so forth—than with more “traditional” or open surgery. That said, in some instances surgeons believe they will have better outcomes if they have both the sight and the feel of the whole area allowed by traditional incisions. The evidence associated with robotic surgery, however, has been considerably less compelling. The lead researcher on robotics at ECRI (formerly known as the Emergency Care Research Institute), a nonprofit organization that brings applied scientific research to assess the effect of medical procedures, devices, drugs, and processes on patient outcomes, recently commented that with publications on robotic surgery with varying study designs and variable conclusions appearing monthly, it becomes challenging to draw definitive conclusions comparing robotic surgery with traditional laparoscopic surgery. It also depends on which type of surgery is being compared. 1 The incremental costs associated with the da Vinci procedure are less debated, with costs ranging from $3,000 to $6,000 more than traditional laparoscopic surgery. As more procedures are performed and more evidence is accumulated, some types of procedures have been found more likely to benefit from robotic surgery, while other types have not. Not surprisingly, the difference tends to be associated with those areas in the body that are difficult
{"title":"Robotic Surgery: An Example of When Newer Is Not Always Better but Clearly More Expensive.","authors":"G. Wilensky","doi":"10.1111/1468-0009.12178","DOIUrl":"https://doi.org/10.1111/1468-0009.12178","url":null,"abstract":"When the US Food and Drug Administration (FDA) first approved the da Vinci surgical robot for clinical use in 2000, many people assumed that robotic surgery would have as much effect on improving patient outcomes as had minimally invasive,orlaparoscopic,surgery.Adecadeafteritsintroduction,laparoscopic surgery and the smaller incisions it uses produced clear evidence that patients generally did better—faster recoveries, shorter hospital stays, less bleeding, and so forth—than with more “traditional” or open surgery. That said, in some instances surgeons believe they will have better outcomes if they have both the sight and the feel of the whole area allowed by traditional incisions. The evidence associated with robotic surgery, however, has been considerably less compelling. The lead researcher on robotics at ECRI (formerly known as the Emergency Care Research Institute), a nonprofit organization that brings applied scientific research to assess the effect of medical procedures, devices, drugs, and processes on patient outcomes, recently commented that with publications on robotic surgery with varying study designs and variable conclusions appearing monthly, it becomes challenging to draw definitive conclusions comparing robotic surgery with traditional laparoscopic surgery. It also depends on which type of surgery is being compared. 1 The incremental costs associated with the da Vinci procedure are less debated, with costs ranging from $3,000 to $6,000 more than traditional laparoscopic surgery. As more procedures are performed and more evidence is accumulated, some types of procedures have been found more likely to benefit from robotic surgery, while other types have not. Not surprisingly, the difference tends to be associated with those areas in the body that are difficult","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"28 1","pages":"43-6"},"PeriodicalIF":0.0,"publicationDate":"2016-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78184083","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Rethinking Science and Politics.","authors":"J. Sharfstein","doi":"10.1111/1468-0009.12177","DOIUrl":"https://doi.org/10.1111/1468-0009.12177","url":null,"abstract":"","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"16 1","pages":"39-42"},"PeriodicalIF":0.0,"publicationDate":"2016-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78142115","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
POLICY POINTS Community health information exchanges have the characteristics of a public good, and they support population health initiatives at the state and national levels. However, current policy equally incentivizes health systems to create their own information exchanges covering more narrowly defined populations. Noninteroperable electronic health records and vendors' expensive custom interfaces are hindering health information exchanges. Moreover, vendors are imposing the costs of interoperability on health systems and community health information exchanges. Health systems are creating networks of targeted physicians and facilities by funding connections to their own enterprise health information exchanges. These private networks may change referral patterns and foster more integration with outpatient providers. CONTEXT The United States has invested billions of dollars to encourage the adoption of and implement the information technologies necessary for health information exchange (HIE), enabling providers to efficiently and effectively share patient information with other providers. Health care providers now have multiple options for obtaining and sharing patient information. Community HIEs facilitate information sharing for a broad group of providers within a region. Enterprise HIEs are operated by health systems and share information among affiliated hospitals and providers. We sought to identify why hospitals and health systems choose either to participate in community HIEs or to establish enterprise HIEs. METHODS We conducted semistructured interviews with 40 policymakers, community and enterprise HIE leaders, and health care executives from 19 different organizations. Our qualitative analysis used a general inductive and comparative approach to identify factors influencing participation in, and the success of, each approach to HIE. FINDINGS Enterprise HIEs support health systems' strategic goals through the control of an information technology network consisting of desired trading partners. Community HIEs support obtaining patient information from the broadest set of providers, but with more dispersed benefits to all participants, the community, and patients. Although not an either/or decision, community and enterprise HIEs compete for finite organizational resources like time, skilled staff, and money. Both approaches face challenges due to vendor costs and less-than-interoperable technology. CONCLUSIONS Both community and enterprise HIEs support aggregating clinical data and following patients across settings. Although they can be complementary, community and enterprise HIEs nonetheless compete for providers' attention and organizational resources. Health policymakers might try to encourage the type of widespread information exchange pursued by community HIEs, but the business case for enterprise HIEs clearly is stronger. The sustainability of a community HIE, potentially a public good, may necessitate ongoing public fun
{"title":"Differing Strategies to Meet Information-Sharing Needs: Publicly Supported Community Health Information Exchanges Versus Health Systems' Enterprise Health Information Exchanges.","authors":"J. Vest, B. Kash","doi":"10.1111/1468-0009.12180","DOIUrl":"https://doi.org/10.1111/1468-0009.12180","url":null,"abstract":"POLICY POINTS\u0000Community health information exchanges have the characteristics of a public good, and they support population health initiatives at the state and national levels. However, current policy equally incentivizes health systems to create their own information exchanges covering more narrowly defined populations. Noninteroperable electronic health records and vendors' expensive custom interfaces are hindering health information exchanges. Moreover, vendors are imposing the costs of interoperability on health systems and community health information exchanges. Health systems are creating networks of targeted physicians and facilities by funding connections to their own enterprise health information exchanges. These private networks may change referral patterns and foster more integration with outpatient providers.\u0000\u0000\u0000CONTEXT\u0000The United States has invested billions of dollars to encourage the adoption of and implement the information technologies necessary for health information exchange (HIE), enabling providers to efficiently and effectively share patient information with other providers. Health care providers now have multiple options for obtaining and sharing patient information. Community HIEs facilitate information sharing for a broad group of providers within a region. Enterprise HIEs are operated by health systems and share information among affiliated hospitals and providers. We sought to identify why hospitals and health systems choose either to participate in community HIEs or to establish enterprise HIEs.\u0000\u0000\u0000METHODS\u0000We conducted semistructured interviews with 40 policymakers, community and enterprise HIE leaders, and health care executives from 19 different organizations. Our qualitative analysis used a general inductive and comparative approach to identify factors influencing participation in, and the success of, each approach to HIE.\u0000\u0000\u0000FINDINGS\u0000Enterprise HIEs support health systems' strategic goals through the control of an information technology network consisting of desired trading partners. Community HIEs support obtaining patient information from the broadest set of providers, but with more dispersed benefits to all participants, the community, and patients. Although not an either/or decision, community and enterprise HIEs compete for finite organizational resources like time, skilled staff, and money. Both approaches face challenges due to vendor costs and less-than-interoperable technology.\u0000\u0000\u0000CONCLUSIONS\u0000Both community and enterprise HIEs support aggregating clinical data and following patients across settings. Although they can be complementary, community and enterprise HIEs nonetheless compete for providers' attention and organizational resources. Health policymakers might try to encourage the type of widespread information exchange pursued by community HIEs, but the business case for enterprise HIEs clearly is stronger. The sustainability of a community HIE, potentially a public good, may necessitate ongoing public fun","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"1 1","pages":"77-108"},"PeriodicalIF":0.0,"publicationDate":"2016-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88898434","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
T he West African Ebola epidemic was a clarion call to transform global health security. Why? After all, more people die every week from enduring diseases such as HIV/AIDS, tuberculosis, and malaria—not to mention noncommunicable diseases— than died throughout the Ebola epidemic. In 1948 the United Nations created the World Health Organization (WHO) precisely to lead the global response to novel infectious diseases with the potential for rapidly spreading across borders. Yet, the WHO and the entire international community were so focused on other priorities (and many countries, like the United States, so self-absorbed with isolated Ebola cases) that they turned their backs on the suffering of the world’s poorest people. The result was an unconscionable amount of illness and death, most of which was entirely preventable. The Ebola epidemic spurred no fewer than 4 global commissions: the WHO Ebola Interim Assessment Panel (July 2015), the Harvard– London School of Hygiene and Tropical Medicine Independent Panel on the Global Response to Ebola (November 2015), the National Academy of Medicine’s Global Health Risk Framework Commission (January 2016), and the United Nations High-Level Panel on the Global Response to Health Crises (February 2016). In addition, the WHO commissioned an independent assessment, which is ongoing, of the functioning of the International Health Regulations during the Ebola epidemic. All 4 reports had striking similarities. Here I examine the reports’ major themes and what it will take to safeguard the future of global health security. This is also a matter that global leaders plan to discuss at the G7 (May 2016 in Japan) and G20 (September 2016 in China) summits.
{"title":"Global Health Security After Ebola: Four Global Commissions.","authors":"L. Gostin","doi":"10.1111/1468-0009.12176","DOIUrl":"https://doi.org/10.1111/1468-0009.12176","url":null,"abstract":"T he West African Ebola epidemic was a clarion call to transform global health security. Why? After all, more people die every week from enduring diseases such as HIV/AIDS, tuberculosis, and malaria—not to mention noncommunicable diseases— than died throughout the Ebola epidemic. In 1948 the United Nations created the World Health Organization (WHO) precisely to lead the global response to novel infectious diseases with the potential for rapidly spreading across borders. Yet, the WHO and the entire international community were so focused on other priorities (and many countries, like the United States, so self-absorbed with isolated Ebola cases) that they turned their backs on the suffering of the world’s poorest people. The result was an unconscionable amount of illness and death, most of which was entirely preventable. The Ebola epidemic spurred no fewer than 4 global commissions: the WHO Ebola Interim Assessment Panel (July 2015), the Harvard– London School of Hygiene and Tropical Medicine Independent Panel on the Global Response to Ebola (November 2015), the National Academy of Medicine’s Global Health Risk Framework Commission (January 2016), and the United Nations High-Level Panel on the Global Response to Health Crises (February 2016). In addition, the WHO commissioned an independent assessment, which is ongoing, of the functioning of the International Health Regulations during the Ebola epidemic. All 4 reports had striking similarities. Here I examine the reports’ major themes and what it will take to safeguard the future of global health security. This is also a matter that global leaders plan to discuss at the G7 (May 2016 in Japan) and G20 (September 2016 in China) summits.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"57 1","pages":"34-8"},"PeriodicalIF":0.0,"publicationDate":"2016-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90818428","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
O n October 29, 2012, the massive rainfall brought on by storm surges from Hurricane Sandy flooded New York City’s streets and underground transit tunnels, cutting off power throughout the metropolis. In anticipation of the storm, New York University’s Langone Medical Center activated its emergency preparedness plan. But the next day, the hospital’s electricity went out and its backup generators failed. The staff, in partnership with local first responders, responded, transferring hundreds of patients, some in critical condition, to nearby hospitals. One news report described nurses carrying newborns that had been on respirators down 9 flights of stairs as they manually pumped oxygen into the babies’ lungs. The story is an example of the impact of severe storms on our health system. It is especially relevant today as the growing threat of climate change is expected to only increase the incidence of severe weather events like Hurricane Sandy. But climate change is more than another underlying cause of poor health and injury. Preparing for and adapting to climate change is also an opportunity for health care systems to reexamine both their ability to remain resilient in a disaster and their role in mitigating climate-related disease burdens by reducing emissions that contribute to climate change. These systemic endeavors will require broad leadership and cooperation over many years. But through such systemic changes, health care systems can position themselves as leaders in helping our nation prepare for climate change as well as in protecting the most vulnerable among us.
{"title":"Shelter in the Storm: Health Care Systems and Climate Change.","authors":"G. Benjamin","doi":"10.1111/1468-0009.12174","DOIUrl":"https://doi.org/10.1111/1468-0009.12174","url":null,"abstract":"O n October 29, 2012, the massive rainfall brought on by storm surges from Hurricane Sandy flooded New York City’s streets and underground transit tunnels, cutting off power throughout the metropolis. In anticipation of the storm, New York University’s Langone Medical Center activated its emergency preparedness plan. But the next day, the hospital’s electricity went out and its backup generators failed. The staff, in partnership with local first responders, responded, transferring hundreds of patients, some in critical condition, to nearby hospitals. One news report described nurses carrying newborns that had been on respirators down 9 flights of stairs as they manually pumped oxygen into the babies’ lungs. The story is an example of the impact of severe storms on our health system. It is especially relevant today as the growing threat of climate change is expected to only increase the incidence of severe weather events like Hurricane Sandy. But climate change is more than another underlying cause of poor health and injury. Preparing for and adapting to climate change is also an opportunity for health care systems to reexamine both their ability to remain resilient in a disaster and their role in mitigating climate-related disease burdens by reducing emissions that contribute to climate change. These systemic endeavors will require broad leadership and cooperation over many years. But through such systemic changes, health care systems can position themselves as leaders in helping our nation prepare for climate change as well as in protecting the most vulnerable among us.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"33 1","pages":"18-22"},"PeriodicalIF":0.0,"publicationDate":"2016-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79809382","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
O nce upon a time, I believed that efforts to repeal the Affordable Care Act (ACA) would wither and die once the ACA’s major Medicaid and private insurance expansions became effective on January 1, 2014. After all, opponents had let Senator Ted Cruz (R-TX) trigger a 3-week federal government shutdown in October 2013 in a desperate final attempt to thwart the expansions. Over the course of 2 open enrollment periods, between 2013 and 2015, as many as 17 million previously uninsured Americans obtained coverage. Surely the worst was over. Now I am not so certain. Since 2010, Americans have witnessed 3 near-death experiences relating to national health reform: first, the election of Scott Brown (R-MA) to the US Senate in January 2010, ending Democrats’ 60-vote filibusterproof majority; second, the US Supreme Court’s decision in June 2012 upholding the constitutionality of the ACA writ large; and third, the November 6, 2012, federal elections in which a victory for presidential candidate Mitt Romney would have augured substantial repeal. By this standard, the October 2013 government shutdown and the 2015 Supreme Court case, King v Burwell, were faux near-death experiences, not the real thing. Now we can foresee another looming near-death experience in the form of the November 8, 2016, elections. If Republicans emerge victorious on November 9 and control the White House, the Senate, and the House of Representatives, they will be able to substantially dismantle the ACA, using the legislative budget reconciliation process that preempts filibusters and requires only 51 votes for passage in the Senate.
曾几何时，我相信，一旦《平价医疗法案》的主要医疗补助和私人保险扩张在2014年1月1日生效，废除《平价医疗法案》(ACA)的努力将会枯萎和消亡。毕竟，反对派曾在2013年10月让参议员特德·克鲁兹(德克萨斯州共和党人)发起了为期三周的联邦政府关闭，以进行最后一次绝望的尝试，以阻止扩张。在2013年至2015年的两次开放登记期间，多达1700万以前没有保险的美国人获得了保险。最糟糕的时候肯定已经过去了。现在我不那么肯定了。自2010年以来，美国人目睹了三次与国家医疗改革有关的濒死经历:第一，2010年1月，斯科特·布朗(R-MA)当选美国参议院议员，结束了民主党的60票多数;其次，2012年6月，美国最高法院做出裁决，明确支持ACA的合宪性;第三，在2012年11月6日的联邦选举中，如果总统候选人米特·罗姆尼(Mitt Romney)获胜，将预示着实质性的废除。按照这个标准，2013年10月的政府关门和2015年最高法院的“金诉伯韦尔案”(King v Burwell)都是虚假的濒死体验，而不是真实的濒死体验。现在，我们可以预见，2016年11月8日的选举将是另一次迫在眉睫的濒死体验。如果共和党在11月9日取得胜利并控制白宫、参议院和众议院，他们将能够利用立法预算和解程序实质性地废除《平价医疗法》，该程序先发制人，只需51票就能在参议院通过。
{"title":"Is the Fate of the ACA Settled or Not?","authors":"J. McDonough","doi":"10.1111/1468-0009.12173","DOIUrl":"https://doi.org/10.1111/1468-0009.12173","url":null,"abstract":"O nce upon a time, I believed that efforts to repeal the Affordable Care Act (ACA) would wither and die once the ACA’s major Medicaid and private insurance expansions became effective on January 1, 2014. After all, opponents had let Senator Ted Cruz (R-TX) trigger a 3-week federal government shutdown in October 2013 in a desperate final attempt to thwart the expansions. Over the course of 2 open enrollment periods, between 2013 and 2015, as many as 17 million previously uninsured Americans obtained coverage. Surely the worst was over. Now I am not so certain. Since 2010, Americans have witnessed 3 near-death experiences relating to national health reform: first, the election of Scott Brown (R-MA) to the US Senate in January 2010, ending Democrats’ 60-vote filibusterproof majority; second, the US Supreme Court’s decision in June 2012 upholding the constitutionality of the ACA writ large; and third, the November 6, 2012, federal elections in which a victory for presidential candidate Mitt Romney would have augured substantial repeal. By this standard, the October 2013 government shutdown and the 2015 Supreme Court case, King v Burwell, were faux near-death experiences, not the real thing. Now we can foresee another looming near-death experience in the form of the November 8, 2016, elections. If Republicans emerge victorious on November 9 and control the White House, the Senate, and the House of Representatives, they will be able to substantially dismantle the ACA, using the legislative budget reconciliation process that preempts filibusters and requires only 51 votes for passage in the Senate.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"1 1","pages":"13-7"},"PeriodicalIF":0.0,"publicationDate":"2016-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79579216","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Phelps, G. Madhavan, R. Rappuoli, S. Levin, E. Shortliffe, R. Colwell
POLICY POINTS Scarce resources, especially in population health and public health practice, underlie the importance of strategic planning. Public health agencies' current planning and priority setting efforts are often narrow, at times opaque, and focused on single metrics such as cost-effectiveness. As demonstrated by SMART Vaccines, a decision support software system developed by the Institute of Medicine and the National Academy of Engineering, new approaches to strategic planning allow the formal incorporation of multiple stakeholder views and multicriteria decision making that surpass even those sophisticated cost-effectiveness analyses widely recommended and used for public health planning. Institutions of higher education can and should respond by building on modern strategic planning tools as they teach their students how to improve population health and public health practice. CONTEXT Strategic planning in population health and public health practice often uses single indicators of success or, when using multiple indicators, provides no mechanism for coherently combining the assessments. Cost-effectiveness analysis, the most complex strategic planning tool commonly applied in public health, uses only a single metric to evaluate programmatic choices, even though other factors often influence actual decisions. METHODS Our work employed a multicriteria systems analysis approach--specifically, multiattribute utility theory--to assist in strategic planning and priority setting in a particular area of health care (vaccines), thereby moving beyond the traditional cost-effectiveness analysis approach. FINDINGS (1) Multicriteria systems analysis provides more flexibility, transparency, and clarity in decision support for public health issues compared with cost-effectiveness analysis. (2) More sophisticated systems-level analyses will become increasingly important to public health as disease burdens increase and the resources to deal with them become scarcer. CONCLUSIONS The teaching of strategic planning in public health must be expanded in order to fill a void in the profession's planning capabilities. Public health training should actively incorporate model building, promote the interactive use of software tools, and explore planning approaches that transcend restrictive assumptions of cost-effectiveness analysis. The Strategic Multi-Attribute Ranking Tool for Vaccines (SMART Vaccines), which was recently developed by the Institute of Medicine and the National Academy of Engineering to help prioritize new vaccine development, is a working example of systems analysis as a basis for decision support.
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T he close relationship between a nation’s physical health and its economic and political health has been a central tenet of statecraft since the rise of the mercantile economy in the 18th century. Especially in England, France, Germany, and Austria during this time, health statistics became an important measure of social cohesion. In the 19th century, politicians, doctors, social reformers, and revolutionary thinkers—from William Farr and Otto von Bismarck to Rudolf Virchow, Edwin Chadwick, Karl Marx, and Frederick Engels—continued to use the physical health of a nation’s citizens as a broad gauge of its social well-being (for classic examples, see Edwin Chadwick’s 1842 Report on the Sanitary Condition of the Labouring Population of Great Britain and Friedrich Engels’s 1845 The Condition of the Working Class in England). Indeed, the arguments they made combined with the data they collected were central to the establishment of a social security health insurance. In the 20th century, policymakers looked to poor health statistics as a harbinger of social and political disequilibrium. One notable example was a 1981 article entitled “Health Crisis in the USSR” by the demographer Nick Eberstadt, who made some startling assertions:1 He found that alcoholism, infant mortality, and suicide rates were taking a horrendous toll on Soviet society and concluded that a society plagued by so many markers of poor health was not sustainable. Coming in the midst of the Cold War, even the most hardened spokespeople from both the Right and the Left found it difficult to believe his conclusion that the Soviet Union was on the verge of collapse. In the weeks and months that followed there appeared a flurry of furious responses in the Review’s letters to the editor and other forums, accusing Eberstadt of grossly exaggerating and misinterpreting the data. On the Right, critics reacted vehemently to the suggestion that the Soviet Union was not the powerful adversary that required huge military budgets. On the Left, the idea that socialism, no matter how corrupted,
自18世纪商业经济兴起以来，一个国家的身体健康与其经济和政治健康之间的密切关系一直是治国之道的核心原则。特别是在这一时期的英国、法国、德国和奥地利，卫生统计数据成为衡量社会凝聚力的重要指标。在19世纪，政治家、医生、社会改革家和革命思想家——从威廉·法尔、奥托·冯·俾斯麦到鲁道夫·维尔肖、埃德温·查德威克、卡尔·马克思和弗雷德里克·恩格斯——继续将一个国家公民的身体健康作为衡量其社会福祉的广泛标准(经典例子，参见埃德温·查德威克1842年的《英国劳动人口卫生状况报告》和弗里德里希·恩格斯1845年的《英国工人阶级状况》)。事实上，他们提出的论点与他们收集的数据是建立社会保障健康保险的核心。在20世纪，政策制定者将糟糕的卫生统计数据视为社会和政治失衡的先兆。一个著名的例子是1981年人口统计学家尼克·埃伯施塔特(Nick Eberstadt)发表的一篇题为《苏联的健康危机》(Health Crisis in Soviet)的文章，他提出了一些令人吃惊的断言:1他发现酗酒、婴儿死亡率和自杀率对苏联社会造成了可怕的影响，并得出结论，一个被如此多的不良健康指标所困扰的社会是不可持续的。在冷战期间，即使是最强硬的左翼和右翼发言人也很难相信他关于苏联处于崩溃边缘的结论。在接下来的几周和几个月里，《评论》给编辑和其他论坛的信件中出现了一阵愤怒的回应，指责埃伯施塔特严重夸大和误解了数据。在右翼，批评人士强烈反对苏联不是需要巨额军事预算的强大对手的说法。左派认为，无论社会主义有多腐败，
{"title":"Injurious Inequalities.","authors":"D. Rosner","doi":"10.1111/1468-0009.12179","DOIUrl":"https://doi.org/10.1111/1468-0009.12179","url":null,"abstract":"T he close relationship between a nation’s physical health and its economic and political health has been a central tenet of statecraft since the rise of the mercantile economy in the 18th century. Especially in England, France, Germany, and Austria during this time, health statistics became an important measure of social cohesion. In the 19th century, politicians, doctors, social reformers, and revolutionary thinkers—from William Farr and Otto von Bismarck to Rudolf Virchow, Edwin Chadwick, Karl Marx, and Frederick Engels—continued to use the physical health of a nation’s citizens as a broad gauge of its social well-being (for classic examples, see Edwin Chadwick’s 1842 Report on the Sanitary Condition of the Labouring Population of Great Britain and Friedrich Engels’s 1845 The Condition of the Working Class in England). Indeed, the arguments they made combined with the data they collected were central to the establishment of a social security health insurance. In the 20th century, policymakers looked to poor health statistics as a harbinger of social and political disequilibrium. One notable example was a 1981 article entitled “Health Crisis in the USSR” by the demographer Nick Eberstadt, who made some startling assertions:1 He found that alcoholism, infant mortality, and suicide rates were taking a horrendous toll on Soviet society and concluded that a society plagued by so many markers of poor health was not sustainable. Coming in the midst of the Cold War, even the most hardened spokespeople from both the Right and the Left found it difficult to believe his conclusion that the Soviet Union was on the verge of collapse. In the weeks and months that followed there appeared a flurry of furious responses in the Review’s letters to the editor and other forums, accusing Eberstadt of grossly exaggerating and misinterpreting the data. On the Right, critics reacted vehemently to the suggestion that the Soviet Union was not the powerful adversary that required huge military budgets. On the Left, the idea that socialism, no matter how corrupted,","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"23 1","pages":"47-50"},"PeriodicalIF":0.0,"publicationDate":"2016-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79051827","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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