• Our Commitment to Eliminate Racial and Ethnic Health Disparities

      Satcher, David (2013-01-09)
      Both the life expectancy and the overall health of Americans have improved greatly over the last century, but not all Americans are benefiting equally from advances in health prevention and technology. There is compelling evidence that race and ethnicity correlate with persistent health disparities in the burden of illness and death. For example, compared with their white counterparts, black babies are twice as likely to die during their first year of life, and American Indian babies are 1.5 times as likely. The rate of diabetes among Native Americans is three to five times higher than the rest of the American population, and among Hispanics it is twice as high as in the majority population. Although constituting only 11% of the total population in 1996, Hispanics accounted for 20% of new tuberculosis cases. Also, women of Vietnamese origin suffer from cervical cancer at nearly five times the rate for white women. Current information about the biologic and genetic characteristics of these populations does not solely explain these health disparities. These disparities result from complex interactions among genetic variations, environmental factors, specific health behaviors, and differences in health care access and quality. While the diversity of the American population may be one of our nation's greatest assets, it also represents a range of health improvement challenges-challenges that must be addressed by individuals, communities, and the nation. The demographic changes that are anticipated during the next decade magnify the importance of addressing disparities in health status; groups currently experiencing poorer health status are expected to grow as a proportion of the total U.S. population. Therefore, the future health of America depends substantially on our success in improving the health of racial and ethnic minorities. A national focus on disparities in health status is also particularly important as major changes unfold in how health care is delivered and financed. In a February 1998 radio address, then-President Clinton committed the nation to an ambitious goal by the year 2010: to eliminate the disparities experienced by racial and ethnic minority populations in six health-related areas, including cancer screening and management, cardiovascular disease, diabetes, HIV/AIDS, immunization rates, and infant mortality. These six health areas were selected for emphasis because they reflect areas of disparity that are known to affect multiple racial and ethnic minority groups at all life stages. Clinton's goal parallels the focus of Healthy People 2010-the nation's health objectives for the twenty-first century-which Donna Shalala, former Secretary of the Department of Health and Human Services (DHHS), and I released inJanuary 2000. Achieving this vision will require a major national commitment to identify and address the underlying causes of higher disease and disability levels in racial and ethnic minority communities. These causes include poverty, lack of access to quality health services, environmental hazards in homes and neighborhoods, and the scarcity of effective prevention programs tailored to the needs of specific communities. The effort will require improved collection and use of standardized data to correctly identify all high-risk populations, and to monitor the effectiveness of health interventions targeting these groups. Research dedicated to a better understanding of the relationships between health status, race, ethnicity, and socioeconomic background will help us acquire new ways to eliminate disparities and to apply our existing knowledge.
    • Site of Medical Care: Do Racial and Ethnic Differences Persist?

      Lillie-Blanton, Marsha; Martinez, Rose Marie; Salganicoff, Alina (2013-01-09)
      Prior to the 1960s, Americans generally obtained health care in racially segregated facilities or from health providers of their own race or ethnicity. Racial, geographic, and economic factors influenced where minority Americans could get their health care. Minority Americans, who were disproportionately low income, relied on a combination of sources of care, such as public hospitals and private charity care, because they were unable to afford the cost of a private doctor. Even middle-income minority Americans largely relied upon racially segregated sources of care because these were the only options available to them. In the past four decades, substantial progress has been made in reducing differences in the major sources of health care used by whites and blacks, as well as other racial/ethnic minority groups. Nonetheless, striking racial/ethnic disparities in health care use and health outcomes persist. While these disparities are well documented, factors underlying these differences are not well understood. The most frequently advanced explanations for current health care disparities focus on the characteristics of the patient (e.g., economic conditions or preferences) or the individual provider (e.g., competence or biases). However, it is conceivable that differences in the primary sources of care used by white patients and minority patients might explain some variations in the content of care. Structural or institutional factors-patient-provider relationships, referral networks, and the availability of resources such as highly trained staff and state-of-the-art technology-of varying sources of care may influence the care that patients obtain. Improving knowledge of the extent to which racial/ethnic differences persist in the site of medical care will inform future investigations of the causes of health care disparities. This study, based on original research, examines whether the major sources of ambulatory medical care of whites, African Americans, and Latinos, given similar insurance coverage, differ substantially in the United States. The intent of the study is to assess whether, at the start of the twenty-first century, race/ethnicity continues to be a primary determinant of where medical care is obtained.
    • The Meanings of "Race" in the New Genomics: Implications for Health Disparities Research

      Lee, Sandra Soo-Jin; Mountain, Joanna; Koenig, Barbara (2013-01-09)
      Eliminating the well-documented health disparities found within the United States population is a laudable public policy goal. Social justice demands that we understand the sources of health inequality in order to eliminate them. A central dilemma is: To what extent are health disparities the result of unequal distribution of resources, and thus a consequence of varied socioeconomic status (or blatant racism), and to what extent are inequities in health status the result of inherent characteristics of individuals defined as ethnically or racially different? How we conceptualize and talk about race when we ask these questions has profound moral consequences. Prior to the Human Genome Project (HGP), scientific efforts to understand the nature of biological differences were unsophisticated. The new technologies for genomic analysis will likely transform our thinking about human disease and difference, offering the promise of in-depth studies of disease incidence and its variations across human populations. In her opening remarks at a meeting of the President's Cancer Panel, which focused on health disparities in cancer treatment in the United States, Dr. Karen Antman noted that racial differences in cancer rates have been reported for decades, "but for the first time, science now has the opportunity to quantify such differences genetically." Will the light refracted through the prism of genomic knowledge illuminate straightforward explanations of disease etiology, offering simple solutions to health inequalities? Or are there consequences, currently hidden in the shadows, that require our attention?
    • The Proposed Patients' Bill of Rights: The Case of the Missing Equal Protection Clause

      Hashimoto, Dean (2013-01-09)
      Following the footsteps of most other states, Massachusetts opened its Office of Patient Protection in January 2001. Established under what the media hailed as a "landmark" patients' bill of rights, the Massachusetts legislature created a state agency empowered to review medical decisions made by health maintenance organizations (HMOs) that are challenged by patients. However, after opening its doors, the agency now faces an immediate and major problem-the lack of any patient complaints. On January 27, 2001, the Boston Globe reported the agency's activity as follows: "[I] n their first three weeks, the medical crusaders in this little office have been more like those proverbial Maytag repairmen-twiddling their thumbs in boredom. The office, established under a landmark patients' bill of rights as a referee between HMOs and clients, has yet to hear a single beef." While the problem may be due to a lack of knowledge about the availability of. the appeals process, the immediate result of this Massachusetts reform mirrors the longer-term experience of other states. Health policy researchers at Georgetown University analyzed the limited reliance of patients on the right to appeal HMO decisions and found that patients rarely exercise their newly found due process rights to appeal treatment denials. For example, in the first five years of Florida's external review process (from 1993 to 1998), only 403 cases arose in a population of 4.4 million state residents enrolled in managed care plans. Despite the relatively small impact of this health care reform effort by various states, it appears that Congress will soon pass similar "landmark" federal legislation.
    • Race and Discretion in American Medicine

      Bloche, M (2013-01-09)
      Rarely has a piece of social science research received more attention than the 1999 study by Kevin Schulman and others reporting large differences in physicians' responses to identical heart disease symptoms presented by black and white actors portraying patients. The 720 physician-subjects who participated in the study referred lower proportions of African-American than white age and sex matched "patients" for cardiac catheterization, a costly, state-of-the-art diagnostic measure, even after the researchers controlled for physicians' subjective impressions of disease likelihood and severity. Critics quickly found errors in the authors' statistical methodology-errors that exaggerated these racial disparities. The New England Journal of Medicine, in which the article appeared, then took the extraordinary step of issuing a partial retraction. Yet publication of the Schulman study did more than any other single event to put the matter of racial disparities in health and medical care on the American public policy agenda-and to frame political discussion of the topic. Hundreds of prior publications reported powerful evidence of racial gaps in life expectancy, morbidity from various illnesses, access to health insurance and services, and the clinical management of disease. But the Schulman study's use of African-American and white actors with identical scripts presented a stark picture of pure racial bias, uncomplicated by the potentially mediating roles of educational background, economic status, or other social cues. The study received national media attention, and months later a congressional appropriations report termed its findings "alarming., Report language spotlighting the Schulman study accompanied federal legislation funding an Institute of Medicine (IOM) inquiry into the scope, impact, and causes of racial bias in American medicine. A variety of other public and private sector initiatives targeted racial bias in American health care as a topic for research, discussion, and intervention.
    • Understanding Disparities in the Use of Medicare Services

      Gornick, Marian; Eggers, Paul; Riley, Gerald (2013-01-09)
      Unexpectedly, the use of health care services has been found to differ substantially across subgroups of a population covered by health insurance. In the Medicare program, persons at risk of poor health tend to use fewer of the types of services that healthier persons use to improve health and prevent disease. Relatively little is known about why patterns of health care among the elderly differ by race and socioeconomic status (SES). That disparities occur so persistently in a program such as Medicare, which was expected to equalize access to care, indicates that there are limitations to what health insurance alone can do to assure equal access to health care. The challenge is to determine what our society can do to ameliorate disparities in health care. Health policy experts from an earlier era can provide some insight into the dilemma of disparities in health care. Two books, published half a century ago, contain papers by members of the New York Academy of Medicine on social medicine, a term intended to evoke the complex interrelationships between health and society. Social medicine was defined in one paper as "medical science in relation to groups of human beings." Underlying the concept of social medicine was the belief that medical science ought to approach health, notjust in terms of treating a patient's illness, but also in terms of the whole of an individual's life and society. The multitude of factors that influence health status and health care led one member of the Academy to observe that the problem of medical care is "more complex than it is taken to be." One paper noted that social security and welfare programs do not change the existing social and economic order but mitigate the hardships created by it, noting (with considerable prescience) that health insurance "does not guarantee health to the insured wage earner nor yet does it make public health measures superfluous." To understand the influence of poverty, education, and occupation on health, members of the Academy advocated an expansion of medical school curricula to include knowledge from the social sciences. As one writer stated, "Medicine's recognition of the part the social sciences play in the total health, either of the individual or of groups, will constitute a milestone in human progress. "
    • Case Studies

      2013-01-09
      530 U.S. 211 (2000) On June 12, 2000, the U.S. Supreme Court, in a unanimous decision written by Justice Souter, held that treatment decisions made by health maintenance organizations (HMOs), acting through their physician employees, are not fiduciary acts within the meaning of the Employee Retirement Income Security Act (ERISA). The petitioners in the case were Carle Clinic Association, P.C., Health Alliance Medical Plans, Inc., and Carle Health Insurance Management Co, Inc. [hereinafter Carle]. Carle functioned as a for-profit HMO, and its physician owners provided medical services to participants whose employers had contracted with it. Respondent Cynthia Herdrich was covered by Carle through her husband's place of employment. The events in question began when a Carle physician, Dr. Lori Pegram, examined Herdrich, who was experiencing abdominal pain. Pegram discovered a mass in Herdrich's abdomen and subsequently scheduled an abdominal ultrasound. Instead of immediately scheduling the study at a local facility, Pegram scheduled the ultrasound for eight days later at a facility staffed by Carle, which was more than fifty miles away from Herdrich's home. During the eight days that Herdrich was waiting for the ultrasound, her appendix ruptured, causing peritonitis. Herdrich recovered $35,000 from a state malpractice action against Pegram. However, the U.S. Supreme Court only considered Herdrich's claim that the provision of medical services under Carle's terms-which reward physician owners for limiting medical care-entailed an inherent or anticipatory breach of an ERISA fiduciary duty, since these terms created an incentive to make decisions in the physicians' self-interest, rather than the exclusive interests of patients. The Court of Appeals for the Seventh Circuit agreed with Herdrich and held that Carle was acting as a fiduciary when Pegram made the decision to postpone Herdrich's care. The U.S. Supreme Court reversed, finding that Heidrich did not have an ERISA claim against her HMO. Six authors from various disciplines were asked to consider the impact of the Court's decision. Their responses follow.
    • Pegram v. Herdrich: A Victory for HMOs or The Beginning of the End for ERISA Preemption?

      Borzi, Phyllis (2013-01-09)
      On June 12, 2000, a unanimous Supreme Court held that treatment decisions made by an HMO, acting through its physicians, are not fiduciary acts under ERISA. Thus the Carle HMO was not liable under ERISA for the harm caused when Pegram, one of Carle's physician/owners, required Herdrich to wait an additional eight days before undergoing a necessary diagnostic procedure and, when Herdrich's appendix ruptured during her wait for the procedure, then required her to receive emergency treatment at a Carle-owned facility fifty miles away, rather than at a nearby hospital. At first blush, this seemed like yet another judicial decision insulating managed care organizations (MCOs) from liability under ERISA. Advocates of expanding patients' rights to sue health plans under legislation before Congress might have been expected to bombard members of Congress with outraged communications decrying Pegram as another illustration of how inadequate ERISA was in protecting participants in employer-sponsored group health plans. But the early euphoria or dismay quickly dissipated as ERISA experts began to focus on the larger legal questions raised by Justice Souter's opinion. In particular, much discussion has ensued regarding the implications of the Pegram decision for preemption cases under which plaintiffs have been permitted to bring state law actions alleging substandard quality of care from their health plans.
    • A Perspective from Within the White Coat

      Chow, R (2013-01-09)
      One can easily generate a noisy and angry discussion in any physicians' dining room in the United States by bringing up the subject of managed care systems and their use of financial incentives to control physicians' behavior. Generally, the reaction will range from a palpable frustration among the younger physicians to a feeling of resignation in the senior colleagues. The latter group will then reflect back on the era before managed care, when compensation was on a per diem basis. The more vocal younger generation will continue to vent their spleens about the illogical and unfair nature of their compensation systems, and then realize that they must quickly return to their respective offices, less their productivity be undermined. Having entered clinical practice during the adolescence of managed care, I can provide one clinician's perspective, but cannot pretend to speak for all physicians. There are many of my colleagues who have taken to arms, securing M.B.A. degrees and reviewing HMO contracts every evening before bed. It is easy to discern who these people are: They talk about covered lives, contractual withholds, and capitation systems. I am not among their number. Naive as it is to say, I chose to enter medicine to take care of patients, and I assumed that I would be compensated fairly and live comfortably. If indeed, I had wanted to maximize my future income, I would have sought my fortune in the business world, or failing that, the legal profession.
    • Dividing Loyalties: Caring for Individuals and Populations

      Jecker, Nancy (2013-01-09)
      Are health maintenance organization (HMO) physicians obligated to act exclusively in the interest of the individual patient? Does the mere existence of financial incentives to limit patient care violate this obligation? To what extent are doctors responsible for the population of patients served by a health plan, or for promoting a fair distribution of health care among society as a whole? These questions come to the fore in the recent U.S. Supreme Court case, Pegram v. Herdrich. In Pegram, Herdrich claimed that the terms of the Carle HMO organization, rewarding its physician owners for limiting medical care, entailed an inherent or anticipatory breach of the physician's fiduciary duty under ERISA. Specifically, the terms of the HMO created "an incentive to make decisions in the physician's self-interest, rather than the exclusive interests of plan participants." Her claim rested on showing first, that treatment decisions made by the HMO, acting through its physician employees, were fiduciary acts under ERISA. Second, her claim required showing that the terms of the HMO violated fiduciary obligations under ERISA to act "solely in the interest of' plan participants and beneficiaries when providing benefits and defraying the reasonable expenses of administering the plan.
    • Pegram v. Herdrich: The Supreme Court Confronts Managed Care

      Jost, Timothy (2013-01-09)
      ERISA, adopted a quarter century ago to reform private pension law, imposed by the end of the twentieth century a seemingly insurmountable barrier to managed care reform. The Supreme Court's decision in Pegram v. Herdrich blocked one path out of the ERISA morass-broader use of breach of ERISA fiduciary obligations suits in federal court. On the other hand, it opened another path to holding HMOs accountable in malpractice cases in state court-and suggested that ERISA might impose fiduciary obligations to disclose incentives on HMOs. It is therefore an important decision. ERISA was intended to give the federal government primary authority for regulating employee pension and benefits plans. As the vast majority of Americans with private health insurance (88%) obtain it through their place of employment, ERISA effectively gives the federal government primary responsibility for regulating private health insurance. Section 514(a) of ERISA provides that ERISA "supersedes" all state laws that "relate to" employee benefits plans. Early Supreme Court decisions read this clause very broadly as preempting state laws that had any "connection with or reference to" a benefits plan. In particular, Pilot Life v. Dedeaux read ERISA as preempting state tort law challenges to egregious coverage denials. While § 514 contains a "savings clause" excluding the traditional state function of insurance regulation from preemption, the Supreme Court initially read this provision very narrowly to cover only regulation of traditional insurance functions. Moreover, § 514(b) (2) (B) prohibits the states from "deeming" ERISA plans themselves to be insurers, which the Court has read as precluding state regulation of self-funded plans. The net effect of the Court's early interpretations of these provisions was to severely restrict the ability of the states to regulate employee benefits plans.
    • Pegram's Significance for Managed Health Care

      Saccoccio, Louis (2013-01-09)
      On June 12, 2000, in a unanimous opinion written by Justice Souter, the U.S. Supreme Court, reversing a decision of the U.S. Court of Appeals for the Seventh Circuit, held in Pegram v. Herdrich that "mixed eligibility" decisions made by HMO physicians are not fiduciary decisions under ERISA . In so ruling, the Court upheld the concept that the reasonable sharing of financial risk with HMO network physicians for providing health care to a given patient population does not run afoul of ERISA's fiduciary requirements. This result is a significant victory for managed health care plans, their network physicians, and their members. Although the decision's impact on the viability of physician risk sharing is clearly positive, the decision's impact on the question of HMO liability under ERISA remains less clear. Some, including the U.S. Department of Labor, argue that this case represents a shift in ERISA preemption law. They argue that Pegram now precludes ERISA preemption of state law causes of action aimed at HMO coverage determinations that involve questions of medical-necessity or experimental or investigational treatments. A more reasonable reading of the case, consistent with its facts, however, leads to the conclusion that Pegram represents nothing more than a common sense answer to a simple question. What law should apply when a treating physician makes a treatment decision that may arguably raise issues of eligibility for coverage? Pegram's answer does not represent a shift in the law regarding ERISA preemption of HMO coverage decisions.
    • Mismanaged Care: The Challenges Facing Judicial Interpretation of Contemporary Health Policy

      Schlesinger, Mark (2013-01-09)
      At a time when the U.S. Supreme Court stands accused of undermining the legitimacy of American democracy, it might seem superfluous to question its wisdom in the interpretation of more mundane matters of public policy. But the Court is rarely given an opportunity to tinker with electoral outcomes. By contrast, it is constantly in the business of interpreting congressional legislation. Doing so involves more than simply establishing the constitutionality of a law. It also requires sensitivity to the substantive implications of a ruling, as reflected in the Court's analysis of congressional intent. These judgments are made difficult when the substantive implications are hard to discern or confusingly complicated. These difficulties can compromise sensible judicial interpretation of laws that shape contemporary health policy.
    • How are states regulating the use of drugs and alcohol during pregnancy?

      2013-01-09
      In March 2001, the United States Supreme Court announced its decision in Ferguson v. City of Charleston, which struck down the Medical University of South Carolina's policy of testing the urine of pregnant women for cocaine without consent, and reporting positive results to local authorities. The Court held that involuntary drug testing of pregnant women violated the Fourth Amendment's prohibition on unreasonable searches and seizures. In light of the Court's decision, the future of state regulation in this area is unclear. The following article by Jean Reith Schroedel and Pamela Fiber considers how states currently approach the regulation of drugs and alcohol during pregnancy and how the Supreme Court's decision may affect the future. Following their piece is a synopsis of each state's existing case and statutory law on the subject, which has been produced by theJournals editorial staff.
    • Punitive Versus Public Health Oriented Responses to Drug Use by Pregnant Women

      Schroedel, Jean; Fiber, Pamela (2013-01-09)
      During the past fifteen years, the term fetal abuse has been applied to physical and developmental harms caused by prenatal drug exposure, but not to other preventable threats to fetal well-being. Although Roe v. Wade established the legal rationale for fetal abuse prosecutions, which held that a state may have a compelling interest in intervening in a woman's pregnancy after the fetus reaches viability, states did not initially use Roe to prosecute pregnant women whose substance abuse threatened fetal wellbeing. The situation began to change in the mid-1980s, when media attention on the problems of "crack babies combined with technological advances in in utero fetal health monitoring to create a public outcry against pregnant substance abusers.
    • Limiting Technology in the Process of Negotiating Death

      Dubler, Nancy (2013-01-09)
      Book Review: Managing Death in the Intensive Care Unit: The Transition from Cure to Comfort. Edited by J. Randall Curtis and Gordon D. Rubenfeld. New York: Oxford University Press, 2001. Pp. 388.
    • Book Notes

      2013-01-09
    • Is the U.S. Public Health System Ready for Bioterrorism? An Assessment of the U.S. Public Health Infrastructure and its Capacity for Infectious Disease Surveillance

      Baxter, Raymond; Steinberg, Caroline; Shapiro, Jennifer (2013-02-23)
      Bioterrorism has become a household word. For years experts have warned of the potential of bioterrorist events, and today we have finally experienced the reality of this particular horror. As the nation garners resources to combat current and future bioterrorist activity, questions and debate arise as to the appropriate allocation of resources. Most funding appears targeted toward vaccines and medical supplies with little focus on the underlying public health infrastructure. However, it is the infrastructure-the organizations and people who comprise the nation's public health system-that will ultimately determine the success of any efforts to fight the spread of infectious diseases, including those resulting from bioterrorism. Within the overarching infrastructure, it is the nation's capacity to conduct infectious disease surveillance-detecting unusual disease patterns, investigating sources of outbreaks, and triggering control efforts-that will play the greatest role in our success or failure in combating infectious diseases. In light of ongoing concerns about the nation's public health infrastructure and infectious disease surveillance capacity, we undertook a study to identify gaps in the system and specific areas in need of improvement. We performed this study on behalf of the Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services. Given recent events, we believe it is important not only to present the gaps in the system as identified by our study, but also to provide readers with a context and framework for discussing surveillance activities. This Commentary presents a discussion of the goals of infectious disease surveillance, a framework for understanding and discussing the U.S. public health infrastructure in which surveillance occurs, and the results of our analysis on gaps in the infectious disease surveillance system.
    • Two Cheers For Employment-Based Health Insurance

      Hyman, David; Hall, Mark (2013-02-23)
      Employment-based health insurance is the Rodney Dangerfield of health policy: it gets no respect from anyone. Liberal enthusiasts of a one-payor system view the existence of employment-based health insurance as a major impediment to the achievement of universal comprehensive coverage. From the opposite end of the political spectrum, free market enthusiasts attack employment-based health insurance on the grounds that individual preferences are systematically ignored, and cost-quality tradeoffs are inappropriately constrained when employers select coverage for employees. Advocates for a patient bill of rights complain that managed care is favored by employers (not employees), and argue that employers are motivated by profits, instead of the best interests of their employees. Prominent health policy scholars and the media routinely condemn the linkage between employment and health insurance. Even employers, who offer coverage as a way of attracting and retaining employees, are at best lukewarm about their role in the coverage market. Given these unfavorable attitudes, it is not particularly surprising that reforming these arrangements has been a perennial topic on the policy agenda--even though most employed individuals with health insurance obtain their coverage through their employers, and the employment-based market provides coverage for approximately 177 million Americans. During the past six decades, thousands of pieces of legislation have been introduced at the state and federal levels, seeking reforms ranging from the incremental to the radical. Legislation has sought to change the tax treatment of health insurance premiums, encourage more people to purchase health insurance on their own, partially or completely eliminate employers from the coverage market, mandate all employers to provide coverage, require employers to include specified benefits or providers in their coverage, and the like. Articles supporting and criticizing each of these competing proposals and offering additional reforms fill the pages of medical, legal, economic, and health policy journals. This Article steps back from this morass of competing proposals and considers the employment-based coverage market from a comparative institutional perspective." This approach allows us to assess the costs and benefits of the existing system against the likely alternatives, and provide a more balanced foundation for assessing proposed reforms. As the title of this Article suggests, we conclude that the employment-based coverage market deserves "two cheers," and relatively modest incremental changes are all that are required (or for that matter, politically likely, during the foreseeable future) to ensure the continued smooth functioning of the employment-based coverage market. Our assessment that the employment-based coverage market deserves "two cheers" is unlikely to satisfy most commentators, irrespective of whether they favor a one-payor system, universal adoption of medical savings accounts, or something in between. The score we assign to employment-based health insurance obviously falls well short of perfection. Yet, it is important to keep in mind that perfection is never an appropriate standard for judging real world policies and institutions."' Any "reform" of the employment-based coverage market will replace the existing institutional arrangements and problems with new (and not necessarily improved) institutional arrangements and problems." Prudent policymaking requires that one has a full appreciation of the advantages and disadvantages of existing arrangements, and a framework for determining whether proposed reforms, on balance, make things better or worse. In this Article, we seek to provide the information and analysis necessary to accomplish both of these goals.