1. Policy entrepreneurship in the Social transformation of American Medicine The Rise of Managed Care and Managed Competition

2. Purpose of this article: Explanation of ideas and actions of elites, the marketing innovations by policy entrepreneurs, to political and business leaders. Explanation of ideas and actions of elites, the marketing innovations by policy entrepreneurs, to political and business leaders. How are health policies successfully implemented? How are health policies successfully implemented?

3. History 1960: Liberal reformers → federal initiatives to expand access to health care. 1960: Liberal reformers → federal initiatives to expand access to health care. The medical proffession manage to retain its cultural authority and improves its economic status. The medical proffession manage to retain its cultural authority and improves its economic status. →→→ BECAUSE: Public policies empfasizes redistribution of resources, without reorganization.

4. 1970: Tension 1970: Tension Medical system Towards expansion VS VS Society and state requiring some means of control over medical expenditures

5. Conservatives and Liberals demand reform. Conservatives and Liberals demand reform. Economic incentives and market competition. Economic incentives and market competition. Star observes: emerging corporate transformation of medicine → diminishing power of physicians. Star observes: emerging corporate transformation of medicine → diminishing power of physicians. Finding ways to rationalize financing and delivery of systems. Finding ways to rationalize financing and delivery of systems. HMO`s one of many reforms. HMO`s one of many reforms.

6. Two threads of corporate transformation of medicine: Two threads of corporate transformation of medicine: Horizontal integrationVertical Integration

7. 1990: From undelivered to dominant form of health care organization. HMO`s become the standard for employer sponsored coverage. 1990: From undelivered to dominant form of health care organization. HMO`s become the standard for employer sponsored coverage.

8. Why interest for HMO`s, even after their poor start? The explanation is divided to a decade before and after the publication of Starrs book: The explanation is divided to a decade before and after the publication of Starrs book: President Nixons ”Health maintainance strategy”(1970-1971, the before decade) President Nixons ”Health maintainance strategy”(1970-1971, the before decade) Universal health insurance(Clinton administration 1993-1994) Universal health insurance(Clinton administration 1993-1994) Public and private initiatives, not independent. Public and private initiatives, not independent.

9. Public Private Public Private Policy changes today => impact on policy alternatives in the future. Policy changes today => impact on policy alternatives in the future. Pierson:” Policy changes creates legacies or feedback in two ways(Skocpol and Pierson): Pierson:” Policy changes creates legacies or feedback in two ways(Skocpol and Pierson):

10. Policy Change Structural effects - Resources and Incentives - Social groups, governmental elites and mass public. Future change? Future change? Block sebsequent reforms Learning effects - Alter distribution of information SubstantivSituational Promotes Promotes/inhibits ReformsReforms

11. Two episodes that are critical for the rise of managed care, and market competition. Regulatory reforms adapted by federal officials Regulatory reforms adapted by federal officials Competition, stimulated by the rise of health maintenance organizations(HMO) Competition, stimulated by the rise of health maintenance organizations(HMO)

12. HMO`s gets support. Right time, right place and right people/network. Right time, right place and right people/network. Highly coverage in New York Times. Highly coverage in New York Times. Washington, veteran insider. Washington, veteran insider. High unemplayment High unemplayment Rising health care costs Rising health care costs Economic boom; but still undercoverage and underinsurance. Economic boom; but still undercoverage and underinsurance.

13. How was this possible? Social forces Social forces Strategically placed individuals at critical junctures. Strategically placed individuals at critical junctures. Context Context Leadership Leadership Ideas Ideas Power Power Attack on professional norms(AMA) Attack on professional norms(AMA) Verification via evidence. Verification via evidence. Political mobilization Political mobilization Power Ideas Leadership

14. Results Inflation in health care slows down. Inflation in health care slows down. Significant policy innovation within short time period. Significant policy innovation within short time period.

15. Impact of Elwood and Enthovens efforts on Public policies IDEAS IDEAS PublicPrivate PublicPrivate -Elites norms -Institutinal capasity -New stakeholders in the market approach

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