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Promoting Private Health Insurance In Australia

Abstract

 
Health insurance policy in Australia has been distinguished by considerable instability over the past five years. This paper reviews the rationale and emerging evidence on three major policy initiatives—a move to allow selective contracting, the introduction of a 30 percent government subsidy for private health insurance, and the abolition of pure community rating. Policy making on private health insurance has been characterized by insufficient attention to research that might provide a stronger evidence basis for policy reforms.

Policy formulation. John Kingdon’s analysis of policy formulation identifies three independent streams—problem recognition, generation of policy proposals, and the political environment—which affect whether issues move to the public agenda and the range of policy alternatives under consideration.³ The political environment, comprising both the governing political party and the balance of organized political interest groups, has been preeminent in shaping Australian health insurance policy development.

The Labor (progressive) Party and interest groups, including public hospital and consumer associations, believe that public insurance should be a universal system rather than a safety net, with the corollary being that private health insurance should be supplementary to Medicare. They criticized the dismantling of the universal health insurance program in the late 1970s, when people were given the ability to opt out of public insurance by taking private insurance.

An alternative view supported by the Liberal and National (or conservative) Parties and interest groups, including private hospitals and most medical provider associations, is that private health insurance is an essential feature of a balanced system comprising both publicly and privately funded and provided health care. They believe that private health insurance provides consumers with valuable choices and complements Medicare by maximizing access to resources in both public and private hospitals.

Private health insurance in Australia and the United States. The major features of the Australian health care system have been comprehensively described elsewhere.⁴ In brief, Medicare provides universal access to free public hospital care, with ambulatory medical and pharmaceutical services also available subject to limited consumer copayments. The program is financed progressively through a combination of general tax revenue and an identified Medicare Levy, equivalent to 1.5 percent of personal taxable income.

Under the National Health Act of 1953, private health insurance is only allowed to cover services not funded under Medicare. Essentially, private health insurance buys access to private hospitals and choice of medical specialists in both public and private hospitals, together with ancillary services such as dentistry and physical therapy. A 1997 opinion poll found that the perceived advantages of private health insurance were to get "quick attention/avoid public hospital waiting lists" (28 percent) and "choice of doctor" for hospital-based medical services (21 percent) and for ancillary services such as dentistry (20 percent).⁵

Despite its universal public insurance system, Australia has a relatively high level of private health expenditure. Among Organization for Economic Cooperation and Development (OECD) countries, the United States is the clear frontrunner, with 57.2 percent of all health spending derived from private financing, but Australia still ranks fifth, with 33.1 percent of health financing coming from the private sector.⁶

The method of financing the private health insurance sector in Australia differs greatly from its U.S. counterpart. In particular, private health insurance is almost entirely purchased directly by individuals in Australia, compared with the U.S. reliance on coverage based on employment. Preferential tax treatment of employer contributions for health insurance, coupled with wage controls in the 1940s, spurred the growth of employment based coverage in the United States.⁷ In contrast, contrast, an Australian Labor government in the 1980s promoted the concept of the "social wage," whereby government would take responsibility for funding social goods such as health (under the Medicare program) and education to supplement the employer cash wage.⁸

Another fundamental distinction relates to regulatory responsibility for private health insurance. While both federal and state governments in Australia are constitutionally empowered to legislate with respect to insurance, federal legislation overrides any inconsistent state legislation. Hence, state governments have never sought to exert regulatory authority over health insurance, ensuring national uniformity in health insurance regulation. The 1945 McCarran-Ferguson Act in the United States reasserted the states’ exclusive regulatory authority over insurance, allowing health insurance plans to escape the growing net of federal antitrust activity on the basis that states regulated these markets in a manner not contradictory to federal purposes. ⁹ However, the Employee Retirement Income Security Act (ERISA) and, more recently, the Health Insurance Portability and Accountability Act (HIPAA) have greatly undercut the states’ regulatory responsibility over private health insurance.

Policy Reforms In Australia

Top Policy Reforms In Australia Conclusions And Policy... NOTES

 
Since 1995 three major reforms—selective contracting, government subsidies for health insurance, and a move away from pure community rating—have been introduced in Australia, albeit in response to shifting views on the policy problem requiring resolution.

Selective contracting. In 1995 the federal Labor government passed legislation allowing health plans to contract selectively with hospitals and doctors. This legislation built upon the successful experience in two of the six states (Victoria and South Australia) where a small number of plans had entered into voluntary agreements with private hospitals to limit consumer copayments.

The impact of the legislation on the two major provider groups, private hospitals and medical specialists, has been markedly different. However, both groups were successful over time in gaining major concessions, which potentially reduced the legislation’s impact in solving the copayment problem.

Impact on private hospitals. The initial round of negotiations between private hospitals and health plans resulted in most plans entering contracts with the majority of private hospitals in their geographic market. For example, by June 1996 one plan had contracts covering 95 percent of all private hospital beds in New South Wales and the Australian Capital Territory. ¹⁰ Federal legislation (stipulating that noncontracted hospitals received a default payment for nonemergency admissions set at less than half the average costs of private hospitals) provided a strong incentive for private hospitals to enter contacts.

However, health plans failed to take advantage of this shift in bargaining power to negotiate price discounts with hospitals. Instead, plans actually increased the average daily benefit paid to private hospitals in 1996 by 40 percent, whereas the average annual increase for the previous five years had been only 5 percent.¹¹ In contrast, the introduction of selective contracting in California in the 1980s witnessed health plans contracting with hospitals at prices 10–20 percent below customary charges.¹² One reason for the apparently apparently paradoxical outcome in Australia was that many plans chose to provide new100 percent hospital coverage products. This benefit largesse resulted in a financial reversal for health plans, which moved from an aggregate operating profit of $33.6 million in 1994–95 to a $44 million operating loss in 1995–96.¹³

Faced with concerns about their financial viability, health plans engaged in more competitive pricing and were more selective in entering contracts. Between 1996 and 2000 health plans’ daily payments to private hospitals grew at an average of only 2.6 percent annually. A tendering process by one of the large health plans resulted in coverage for only 73 percent of private hospital beds in Victoria and 80 percent in South Australia, moving closer to the concept of a network of preferred providers.¹⁴ The Conservative federal government (elected in 1996) feared that selective tendering could jeopardize the financial viability of private hospitals that failed to win contracts. This fear was not without some foundation, given the relative imbalance in market power between the health insurance and private hospital sectors in most states (Exhibit 1).

Impact on medical specialists. Australian medical specialists generally operate as independent practitioners and are not organized into groups. The contracting legislation envisaged that health plans would enter into individual contracts directly with medical specialists to determine payment arrangements for the services provided by these doctors to privately insured persons.

Unlike private hospitals, medical specialists have strongly resisted entering contracts with health plans. The federal Department of Health and Family Services, aware of the profession’s concerns about the introduction of U.S.-style managed care, nonetheless estimated that about 20 percent of doctors would be participating in contracts within two years.¹⁶ This estimate proved to be overly optimistic: May 1998 data indicated that only two health plans had contracts with 200 doctors nationwide.¹⁷ No doubt, some American physicians would observe with nostalgia this reversal of market power, and the continuing dominance of fee-for-service medicine, being exhibited across the Pacific. Data from the American Medical Association for 1998 indicate that 92 percent of all nonfederal physicians had managed care contracts, comprising about 45 percent of their practice revenues.¹⁸

In 1995 the Labor government had introduced selective contracting to reduce consumer copayments, while simultaneously keeping inflationary pressure down by prohibiting health plans from paying reimbursement reimbursement above the government-determined medical schedule fee. The return of a Liberal-National government in 1996 saw a shift in emphasis in response to continuing reductions in health insurance membership and physicians’ resistance to health plan contracts. The government now allowed health plans to pay benefits above the schedule fee, under both contract and noncontract arrangements. It also legislated that contracts would be required "to maintain the medical practitioner’s practitioner’s professional freedom, within the scope of accepted clinical practice."¹⁹ Whether this provision is effective in maintaining clinical autonomy remains to be fully tested over the longer term. Certainly, to date, the U.S. arsenal of managed care tools, such as preadmission review, physician profiling, and practice guidelines, is not yet part of the Australian health insurance landscape.

The 30 percent government rebate. In July 1997 the government attempted to stem the erosion in private health insurance membership through providing a meanstested rebate, which was capped at a flat amount, irrespective of the cost of health insurance purchased. In January 1999 this limited scheme was replaced by a new, open-ended 30 percent rebate for private health insurance, available to everyone with such insurance. Here I examine some evidence of the impact of this rebate.

Private health insurance participation. Private health insurance participation declined from 50 percent of the population in 1984 to a low of 30.1 percent in December 1998 (Exhibit 2). Neither the introduction of selective contracting nor the means-tested rebate had any impact on increasing insurance coverage, although the government has argued that both of these initiatives were important in slowing the decline in coverage through greater retention of existing members.

View larger version (14K): [in this window] [in a new window] EXHIBIT 2 Private Health Insurance Coverage In Australia, 1984–2000

The data in Exhibit 2 strongly suggest that the major growth in health insurance coverage occurred in anticipation of the abolition of pure community rating, with the 30 percent rebate having minimal impact on coverage. An alternative interpretation is that the reforms had a synergistic effect, with the impact of the 30 percent rebate being experienced over a delayed twelve-to-eighteen-month period, rather than immediately. However, data on the likely distributional impact of the rebate and recent changes in the age composition of private health insurance (discussed below) provide support for attributing the majority of the growth in health insurance coverage to the community rating reforms.

Efficiency. Initial government estimates of the 30 percent rebate indicated an annual cost to government of $923 million, considerably up from the $326 million annual cost of the earlier targeted rebate scheme introduced in 1997. However, following the substantial increase in health insurance membership prior to the community rating changes, an independent independent estimate of the rebate indicates a total annual cost of $1.492 billion.²¹

Prior to the rebate’s introduction, it was estimated that 90 percent of the rebate would be paid to existing health fund members, with only 10 percent used to generate new membership.²² In its first year of operation, the number of people covered by private health insurance increased by 294,000, meaning that only 5 percent of the rebate went toward new members.²³ This equates to the rebate costing government about $3,150 for every newly insured person, whereas the average individual health insurance premium in 1998–99 was about $380.²⁴ However, proponents of the rebate argue that it is also important in rewarding people who have maintained their private health insurance. Moreover, the administration of a rebate targeted to only new members is extremely complex and would create perverse incentives to drop and then rejoin health insurance.

Another issue relates to the relative efficiency of public and private hospitals. A recent study found that after adjusting for patient case-mix and differences in the financing components, Australian public hospitals were able to treat patients at 91 percent of the cost incurred by private hospitals.²⁵ While the relative efficiency of public and private hospitals is a controversial issue, this study suggests that the expenditure on the rebate could have been applied more efficiently through supporting public hospitals directly.

Finally, private health insurance plans operate with considerably higher administrative costs (12.0 percent in 1998–99, or $320 million) than the government’s public health insurance program (3.5 percent).²⁶ The redirection of the insurance subsidy to the public sector would result in more government funding being applied to the direct provision of health services, rather than being partly consumed in greater management expenses.

Equity. An equity issue raised by the rebate is its disproportionate distribution to high-income persons, arising from the strong association between income and purchase of private health insurance. In 1992–93 nearly 70 percent of households with annual incomes greater than $22,576 had health insurance; only 20 percent of households with incomes less than $4,515 had coverage.²⁷ Hence, the 30 percent rebate is more likely to be taken up by middle-and high-income consumers, whose purchase decision is less likely to be influenced by the government subsidy.

A distributional study found that in 1993–94 the cost of health insurance premiums consumed almost 11 percent of household income for low-income families, but only 2 percent for high-income families.²⁸ This study also found that in 1995 the targeted rebate scheme was likely to reduce health insurance spending from about 14 percent to 11 percent of total household spending for low-income families, which is likely to be insufficient in affecting the purchase decision for most households.

The application of the rebate to ancillary insurance has also been strongly criticized on equity grounds. In 1999–2000 private health insurance plans spent $675 million on ancillary services, or about 28 percent of their total expenditure. The largest single contributor to ancillary benefits that year was dental services, at $345 million.²⁹ Public health advocates have highlighted the inequity in a federal government subsidy of some $103 million annually for the provision of private dental services received principally by high-and middle income persons, in the context of the federal government’s 1996 abolition of a public dental health scheme directed at low-income persons for an annual cost of $54 million.³⁰

Relaxation of community rating. Since 1953 Australian private health insurance has been subject to pure community rating, with family composition or benefit package being the only factors on which prices have been allowed to vary. The federal government has not allowed either access to or the price of insurance to be affected by factors including age, sex, health status, previous use of health services, employment status, or occupation.

In contrast, pure community rating is uncommon in the U.S. individual health insurance market, with New York, and more recently New Jersey and Vermont, being the only states to enact legislation requiring it.³¹ In the United States the historical shift away from the solidarity principle, which was the cornerstone of the early Blue Cross/Blue Shield plans, to experience rating based on "actuarial fairness" corresponded with commercial insurers’ entry into the market.³² Similarly, the 1990s witnessed the entry of new commercial insurers into the Australian health insurance market, previously the domain of nonprofit mutual companies.

In Australia commentators on both the Left and the Right have questioned the value of continuing to require pure community rating for private health insurance. Market based commentators have warned that in the context of universal public insurance, adverse selection associated with community rating is leading to a continuing decline in health insurance participation. Interestingly, this contrasts with the U.S. situation, where the adoption of pure community rating is generally regarded as a device to arrest adverse selection in the private insurance market, in which most coverage is held. In Australia progressive commentators have also questioned the need for community rating, pointing to Medicare’s role in undertaking the redistributive function of social insurance.

In July 2000 the federal government introduced a new regulatory framework called "lifetime community rating." Under this system, the price of health insurance now varies according to the age at which one joins, with 2 percent increments for each year above a base age of thirty years to a maximum of sixty-five years, equivalent to a maximum 70 percent price differential. Under transitional arrangements, anyone who purchased health insurance before the change was credited with a nominal joining age of thirty years and avoided the age penalty. Also, anyone age sixty-five or older at the scheme’s introduction can buy insurance now or at any time in the future at the thirty-year-old base rate.

Evaluating the impact. The government’s stated rationale for this change is threefold: first, to promote continuity in membership; second, to improve the risk profile of health insurance by encouraging greater participation by younger, healthier persons; and finally, to encourage greater overall participation in health insurance.

At the time of this writing in early 2001, it was too soon to assess the impact on membership continuity. However, the government does appear to have been very successful both in increasing private health insurance participation and in improving the risk profile of the privately insured population.

In the three months immediately preceding the introduction of the community rating changes, some 2.08 million persons (equivalent to almost 11 percent of the Australian population) joined private health insurance, presumably to avoid paying the age-related penalties. In response to this increased demand, the government extended the 30 June deadline to 15 July 2000, allowing people an extra two weeks to join health insurance at the thirty-year-old base rate. Accordingly, a further 550,000 persons joined private health insurance in the September 2000 quarter, bringing coverage to 45.8 percent of the population. Critics of the rebate attribute some of this large increase in membership to a six month, $8.7 million advertising campaign urging people to "Run for Cover."

Exhibit 3 shows the substantial improvement in age composition of private health insurance associated with the community rating initiative. In summary, persons ages 30–64 comprised 59 percent of the new membership growth; persons ages 0–29 comprised 39 percent of the growth, while persons age 65 or older accounted for only 2 percent of the growth. The new influx of younger members has reversed the deteriorating risk profile, so that as of September 2000 persons age 65 or older accounted for only 10.5 percent of members, compared with 14.6 percent in 1998–99.

Another potential impact of the community rating changes for suggested future evaluation is the price of private health insurance. Prior to the implementation of the community rating initiative, the federal health minister indicated that actuarial estimates suggested that premiums could be 10–12 percent cheaper within ten years.³³ However, it is likely, in view of the substantial improvement in risk profile associated with the change, that there may now be calls for the industry to make significant reductions in health insurance premiums in the short term.

Conclusions And Policy Implications

Top Policy Reforms In Australia Conclusions And Policy... NOTES

 
Private health insurance policy in Australia has been subject to much volatility over the past five years, with some policies seemingly introduced without the benefit of much evidence. Kingdon’s model of policy formulation is helpful in understanding the rationale for some of the policy shifts.

Kingdon distinguishes between the contributions of partisan politics and the role of interest groups and policy entrepreneurs in setting the policy agenda or affecting the policy alternatives under consideration. The political stream, particularly the governing political party, has been critical in shaping problem recognition and, hence, in formulating policy options. Over the past five years the defined policy problem in Australia has shifted to include issues as diverse as consumer copayments, declining private health insurance membership, concerns about the possible emergence of managed care, and monopsony power in the health insurance sector.

Interest groups have tended to be reactive, consistent with Kingdon’s view of interest group activity as generally focusing on negative blocking, rather than promoting new policy options. Hence, private hospital and medical associations have been successful in lobbying to change elements of the government’s selective contracting reforms.

Kingdon recognizes the role of policy entrepreneurs who are responsible for coupling solutions to problems. Probably the most clear-cut example of this behavior has been the role of the Industry Commission, in its seminal 1997 report examining the status of the health insurance sector and future reform options. This report was critical in instigating informed debate on major changes to community rating, which had previously not been on the political radar screen. The community rating changes represented a quantum leap in thinking about industry reform, in both the relative sophistication of the analysis undertaken and the broad consensus supporting the reform. Moreover, the government has agreed to an independent review of the community rating initiative, scheduled to occur three years after its implementation.

In contrast, the government did not release any detailed research or analysis to justify the selective contracting and government rebate initiatives. The government was also, perhaps intentionally, vague on the specific objectives sought from these reforms. This more opaque policy-making framework is consistent with Charles Lindblom’s model of "muddling through."³⁴ Under this model, policy making does not proceed through a rational and comprehensive analysis of all possible reform options. Instead, goals are not clearly stated, as this might impede the development of political support; interest groups may not agree on the reform option if there is no underlying agreement on the goals to be achieved.

Prior to the introduction of the 30 percent rebate, health services researchers undertook some preliminary analyses, which raised questions about the rebate’s likely impact. However, these concerns were overridden, given the broad electoral support for an initiative resulting in a 30 percent cut in the price of private health insurance. Further research on the health insurance initiatives may be inhibited, as it has been suggested that the government may not welcome findings critical of these initiatives.³⁵ Australian health services research is in its infancy compared to the United States, with a strong dependence on government funding. Policy making on private health insurance has been characterized by insufficient attention to research that might provide a stronger evidence basis for policy reforms.

The early evidence on the impact of the health insurance initiatives suggests that private health insurance has "turned the corner," escaping the death spiral of decreasing membership and a deteriorating risk profile. Whether this results in another more serious policy consequence—a substantial shift of resources from the public to the private sector and declining public support for universal health insurance—remains to be seen. However, the current government policy of providing significant financial support for private health insurance would seem to be more consistent with a philosophy of private health insurance being an active competitor of, rather than a supplementary adjunct to, universal public health insurance in Australia.

Editor's Notes

 
Sharon Willcox is a health services policy consultant with the New South Wales Department of Health. In 1999/2000 she was based at the Institute for Health Care Research and Policy, Georgetown University, as a Harkness Fellow in Health Care Policy.

The author thanks Stephen Duckett, Karen Pollitz, Paula Wilton, and an anonymous reviewer for helpful comments on a previous version of this manuscript, and staff of the Private Health Insurance Administration Council and the Australian Private Hospitals Association for data provision. This research was undertaken while the author was a Harkness Fellow in Health Care Policy with support from the Commonwealth Fund. The views expressed here are those of the author and should not be attributed to the Commonwealth Fund or the New South Wales Department of Health.

NOTES

Top Policy Reforms In Australia Conclusions And Policy... NOTES

 

1. The Medibank program was introduced in 1975 but was progressively dismantled following the return to power of a Liberal-National federal government. Its successor, Medicare, took effect in 1984, following the reelection of a Labor government.
2. G.R. Palmer, "Evidence-Based Health Policy-Making, Hospital Funding, and Health Insurance," Medical Journal of Australia 172, no. 3 (2000): 130–133.
3. J.W. Kingdon, Agendas, Alternatives, and Public Policies (New York: HarperCollins College Publishers, 1995).
4. See, for example, S. Altman and T. Jackson, "Health Care in Australia: Lessons from Down Under," Health Affairs (Fall 1991): 129–146; G. Gray, "Access to Medical Care under Strain: New Pressures in Canada and Australia," Journal of Health Politics, Policy and Law (December 1998): 905–947; and J. Hall, "Incremental Change in the Australian Health Care System," Health Affairs (May/June 1999): 95–110.
5. TQA Research, Health Care and Insurance, Australia 1997 (Melbourne: TQA Research, 1997).
6. J.R.G. Butler, "Health Expenditure," in Economics and Australian Health Policy, ed. G. Mooney and R. Scotton (Sydney: Allen and Unwin, 1998), 40–71.
7. J.R. Gabel, "Job-Based Health Insurance, 1977–1998: The Accidental System under Scrutiny," Health Affairs (Nov/Dec 1999): 62–74.
8. Health Issues Centre, Medicare: A Double-Edged Sword (Melbourne: York Press, 1987).
9. J. Mashaw and S. Rose-Ackerman, "Federalism and Regulation," in The Reagan Regulatory Strategy: An Assessment, ed. G. Eads and M. Fix (Washington: Urban Institute, 1984), 111–145.
10. Industry Commission, Private Health Insurance, Report no. 57 (Canberra: Commonwealth of Australia, 1997).
11. This is based on the author’s analysis of data from the Private Health Insurance Administration Council Annual Reports 1990–91 to 1999–2000. Analysis based on total hospital benefits paid to private hospitals per bed day indicates annual percentage growth as follows: 1990–91, 9.3 percent; 1991–92, 6.8 percent; 1992–93, 4.2 percent; 1993–94, 2.9 percent; 1994–95, 3.3 percent; 1995–96, 40.3 percent; 1996–97, 5.3 percent; 1997–98, 0.2 percent; 1998–99, 0 percent; 1999–2000, 5.1 percent.
12. L. Johns, M.D. Anderson, and R.A. Person, "Selective Contracting in California: Experience in the Second Year," Inquiry 22, no. 4 (1985): 335–347.
13. Dollar amounts are cited as U.S.$ in the paper, with a conversion rate equivalent to A$1 = $U.S.0.5427. Australian Financial Review (30 January 2001). Data are from Private Health Insurance Administration Council, Annual Report 1995–1996 (Canberra: Commonwealth of Australia, 1996).
14. National Mutual Health Insurance, Briefing Paper: Competitive Tendering for Private Hospital Services (Melbourne: NMHI, February 1998).
15. H. Owens, "Health Insurance," in Economics and Australian Health Policy, 172–191.
16. M. Wooldridge, Health Legislation Amendment Bill (No. 2) 1997: Second Reading Speech (Canberra: Commonwealth of Australia, 27 November 1997).
17. Commonwealth Department of Health and Family Services, Contracted Medical Practitioners List (Canberra: DHFS, May 1998).
18. R.M. Scheffler, "Physician Collective Bargaining: A Turning Point in U.S. Medicine," Journal of Health Politics, Policy and Law (October 1999): 1071–1076.
19. Commonwealth of Australia, National Health Act 1953, Reprint 6, as in force 25 August 1998, Section 73BDA, Medical Purchaser-Provider Agreements.
20. Industry Commission, Private Health Insurance, Report no. 57.
21. L. Segal, Supplementary Paper for the Round Table: Senate Community Affairs Reference Committee First Report—Public Hospital Funding and Options for Reform (Melbourne: Health Economics Unit, Centre for Health Program Evaluation, Monash University, 15 August 2000).
22. J. Deeble, Submission to the Senate Community Affairs Legislation Committee Inquiry on the Private Health Insurance Incentives Bill, 1997 (Canberra: Australian National University, 1998).
23. The increased health insurance coverage associated with the community rating reforms means that a greater share of the rebate is now flowing to new members.
24. Australian Competition and Consumer Commission, Report to the Australian Senate on Anti-Competitive and Other Practices by Health Funds and Providers in Relation to Private Health Insurance, for the Period Ending 31 December 1999 (Canberra: ACCC, 2000).
25. S.J. Duckett and T.J. Jackson, "The New Health Insurance Rebate: An Inefficient Way of Assisting Public Hospitals," Medical Journal of Australia 172, no. 9 (2000): 439–442.
26. Private Health Insurance Administration Council, Annual Report 1998–1999 (Canberra: Commonwealth of Australia, 1999).
27. Australian Bureau of Statistics, Health Insurance Survey, Australia, Catalogue no. 4335.0 (Canberra: ABS, June 1992).
28. D. Schofield, S. Fischer, and R. Percival, Behind the Decline: The Changing Composition of Private Health Insurance in Australia, 1983–1995, Discussion Paper no. 18 (Canberra: National Centre for Social and Economic Modelling, 1997).
29. Private Health Insurance Administration Council, Annual Report 1998–1999.
30. S.J. Duckett and P. Agius, The Social Origins of Health and Well-Being: From the Planetary to the Molecular Conference Proceedings (Canberra: Australian National University, 2000).
31. M.A. Hall, "An Evaluation of New York’s Reform Law," Journal of Health Politics, Policy and Law (February 2000): 71–99; K. Swartz and D.W. Garnick, "Lessons from New Jersey," Journal of Health Politics, Policy and Law (February 2000): 45–70; and M.A. Hall, "An Evaluation of Vermont’s Reform Law," Journal of Health Politics, Policy and Law (February 2000): 101–131.
32. D.A. Stone, "The Struggle for the Soul of Health Insurance," Journal of Health Politics, Policy and Law (Summer 1993): 286–317.
33. M. Wooldridge, Transcript of Interview, 7.30 Report, 12 May 1999.
34. C.E. Lindblom, "The Science of Muddling Through," Public Administration Review (Spring 1959): 79–88.
35. Editorial, "Criticism of 30 Percent Rebate: Trickle Becoming a Flood," Health cover (Oct/Nov 2000): 1–5.

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