Lorian Hardcastle

Improving the Population's Health: The Affordable Care Act and the Importance of Integration

Despite evidence indicating that public health services are the most effective means of improving the populations health status, health care services receive the bulk of funding and political support. The recent passage of the Affordable Care Act, which focused on improving access to health care services through insurance reform, reflects the primacy of health care over public health. Although policymakers typically conceptualize health care and public health as two distinct systems, gains in health status are most effectively and cost-efficiently achieved through their integration into a single health system. The Act does little to compel integration; however, there are numerous opportunities to encourage the coordination of public health and health care in the Acts implementation.

Do Damages Caps Reduce Medical Malpractice Insurance Premiums?: A Systematic Review of Estimates and the Methods Used to Produce Them

Despite common claims made in policy debates, the theoretical connection between tort reform and medical malpractice insurance premiums is ambiguous. Simple models suggest reforms such as statutory damages caps reduce premiums. More elaborate models that account for changes in physician behavior suggest caps might increase or have no impact on premiums. A number of empirical studies have been conducted to estimate the impacts of caps on premiums, and several qualitative literature reviews have attempted to draw general conclusions from the literature. No review, however, has offered a comprehensive and systematic analysis of the full set of empirical studies. This chapter fills that gap. We provide a first glimpse at the wide methodological variations in the studies that employ regression analysis to estimate the impacts of caps on medical malpractice insurance premiums. We describe 16 empirical studies that report 197 estimates of the impact of caps on premiums. Using a theory-driven framework to develop a set of best practices, we find that little weight can be put on any one study due to broad methodological shortcomings. This chapter highlights the need for better data and additional research on the impact of caps on premiums.

Tough choices: private sale of drugs in public hospitals

In their efforts to sustain publicly funded health care, governments are increasingly deciding that some drugs are not sufficiently beneficial to merit public funding. For example, the Ontario government has elected not to fund bortezomib. The administration of such cancer drugs requires nursing staff and supervision and, with drugs such as ibritumomab, nuclear medicine facilities. Because of the cost of having drugs administered privately and the limited number of private clinics in Canada, some patients wish to pay to have these drugs administered in public hospitals. Until recently, as a matter of policy, public hospitals in Canada did not allow this, although some are now reportedly allowing such sale. In this article, we discuss what Canadian provinces can do in terms of legislation, what they should do in terms of policy and what they may be compelled to do if there is a successful challenge under the Canadian Charter of Rights and Freedoms. Although we refer to Ontario’s statutes, our conclusions are of broader interest because all Canadian provinces have legislation that limits the private sector. Furthermore, all jurisdictions with public health insurance struggle to determine which drugs are sufficiently cost-effective to attract public funding. Even in the United States, with its greater reliance on private insurance, the marginal effectiveness and high cost of new drugs is leading some to question the ethics and the policy effects of selling these drugs.