In This Issue

The first article in this issue of the Milbank Quarterly, “Inside the Sausage Factory: Improving Estimates of the Effects of Health Insurance Expansion Proposals,” by Sherry Glied, Dahlia K. Remler, and Joshua Graff Zivin, explains how economists predict the effects of proposals to expand access to health insurance. The authors also offer a proposal for addressing the reasons why it can be difficult or impossible to evaluate competing predictions. The topic is timely. Rapidly rising health care costs in a weak economy are again creating the political conditions in the United States for serious debate about expanding health insurance coverage. Consideration of any option requires estimates of its expected effects, particularly cost and the number of people who would obtain coverage. Various individuals and organizations inside and outside government generate such estimates, using available data, knowledge, and (sometimes proprietary) econometric models. These estimates usually differ, sometimes substantially, and it can be difficult to understand why. This is unfortunate, because the political viability of policy proposals may be at stake.

Glied, Remler, and Zivin begin with a general discussion of what goes into the estimation process, including the different kinds of models that are used and the information needed to predict the effects of policy changes that will alter the cost of health coverage for a class of beneficiaries. Predicting the decisions that millions of people, including employers, will make in response to new circumstances is a major part of estimation. The article makes it clear why it should not be surprising if different modelers do not agree on a proposal’s likely cost and coverage effects. The problem is that users of the information cannot tell why the estimates differ.

Glied, Remler, and Zivin offer a remedy—a proposal for making the modeling process transparent, using what they term a reference case. The idea is for modelers to adopt some conventions that would enable users to see and assess the decisions and assumptions that translate into differences among predictions of cost and coverage. Policymakers could then understand why estimates differ and decide which assumptions they prefer. They would also better understand the extent and nature of uncertainty about a proposal’s likely effects. Although Glied, Remler, and Zivin would like to see modelers voluntarily adopt conventions of transparency, they believe that the users of budget estimates could help by demanding standardization that would facilitate comparisons of estimates. Thus, policymakers in Congress and the executive branch of government are also an audience for the authors’ reform message.

The second article in this issue is based on the history of an invention. “Patents and Innovation in Cancer Therapeutics: Lessons from CellPro,” by Avital Bar-Shalom and Robert Cook-Deegan, tells the story of the arrested development of a medical technology that grew out of NIH-supported research. It raises questions about the relations between universities and industry and, more important, about the adequacy of the current legal framework for ensuring that the American public will benefit from taxpayers’ investments in research. Patents provide incentives for the research and development that can lead to new products. But control of a patent also can be used to keep useful innovations from the market in order to protect existing products. The 1980 Bayh-Dole Act includes provisions to promote the commercial use of inventions growing out of federally funded research. The first use of one of those provisions occurred in the CellPro case. CellPro, a company that had developed a stem cell separation technology based on a patent that Johns Hopkins University licensed to Baxter Healthcare, which had a competing product, petitioned the NIH under that act’s provisions to allow it to “march in” and compel licensing for commercial use of a patent based on federally funded research. The NIH refused. Bar-Shalom and Cook-Deegan use the CellPro case to identify areas in the Bayh-Dole Act that might require additional legislative attention to ensure that the act’s original intentions are realized.

In “Racial and Spatial Relations as Fundamental Determinants of Health in Detroit,” Amy J. Schulz, David R. Williams, Barbara A. Israel, and Lora Bex Lempert use data from Detroit to illuminate a problem that has attracted much concern in recent years: ethnoracial differences in morbidity and mortality. Much of the literature on this topic focuses on what happens to people when they seek medical care. Schulz and her colleagues, however, are concerned with what they term fundamental determinants that underlie many other causal factors. They argue that race-based segregation is such a fundamental cause.

The authors show how the African American population of Detroit became increasingly segregated into low-income neighborhoods in the last third of the 20th century. They then examine the health consequences of this segregation. A large number and variety of risk factors are connected to geographic segregation, such as the withdrawal of resources, exposure to environmental risks, stressors, the loss of community infrastructure, and detrimental health behaviors. While Schulz and her colleagues recognize the value of strategies to address these “intermediate and proximate social factors,” they conclude that racial disparities cannot be eliminated so long as the fundamental cause prevails.

In “Voices Unheard: Barriers to Expressing Dissatisfaction to Health Plans,” Mark Schlesinger, Shannon Mitchell, and Brian Elbel address an important topic in a health care system that is increasingly oriented toward the logic of consumerism. To what extent and under what circumstances will people complain about problems pertaining to their health care? Schlesinger, Mitchell, and Elbel first summarize the theoretical and empirical literature regarding “voicing” behavior by consumers and consider its implications for medical care. From this literature, they derive hypotheses regarding the circumstances under which enrollees are likely to voice complaints to health plans, and they test these hypotheses using data from a national survey carried out by the Kaiser Family Foundation. They find that although voicing is common, it occurs at low rates in certain vulnerable populations. Their analysis also provides qualified support about the effectiveness of state regulatory initiatives to enhance consumer voice in managed care. They conclude by discussing the implications of their findings for future research and for public policy.

The final article in this issue is “The Foreignness of Germs: The Persistent Association of Immigrants and Disease in American Society,” by Howard Markel and Alexandra Minna Stern. The article covers three periods, from the early to late 20th century, and grew out of a project to commemorate the 100th anniversary of the Milbank Memorial Fund in 2005 (see also C.E. Rosenberg in MQ 80.2:237–60). Markel and Stern provide rich detail about how public health concerns became linked to immigration policy in the late 19th century when immigrant groups were associated with stigmatized health conditions. Even though U.S. immigration policies subsequently changed, aspects of the historical patterns lingered. The authors show that the social perceptions of threats of infected immigrants have exceeded the true dangers, in part because of illnesses that developed after their arrival in this country. In their words, “anti-immigrant rhetoric and policy have often been framed by an explicitly medical language, one in which the line between perceived and actual threat is slippery and prone to hysteria and hyperbole.” By the end of the century, both immigration law and the nature of immigration itself had changed (planes rather than ships), but Markel and Stern still can detect echoes of earlier arguments and policies, particularly in the response to AIDS. They warn against the tendency to “conflate disease with foreigners and particular ailments with specific ethnic, racial, or sexual minorities.”

Bradford H. Gray
Editor, The Milbank Quarterly

Author(s): Bradford H. Gray

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Volume 80, Issue 4 (pages 599–602)
DOI: 10.1111/1468-0009.00183-i5
Published in 2002