New Governance and Soft Law in Health Care Reform

Abstract

A contemporary health care reform is underway, associated with a set of reformers who are active nationally and locally at the doctor/patient level, the health care institution level, and the policy level. This reformist energy is associated with processes in law and policy that can be called new governance and soft law. These processes are different from previous understandings of how health care can be governed, such as self-regulation, market forces, and new deal command and control regulation. These processes are taking hold and are visible in the public and private sectors and through out the health care industry. The paper discusses the relationship between resolving health care conundrums, such as universal access, eliminating racial and ethnic disparities and embedding information technology, and the new processes.There are six innovations that derive from the interaction between new governance, soft law, and reform processes: alternative sites for deliberation, consumer and patient participation, different roles for government, redesigned organizational forms, and new tools for regulation and resolving disputes. Each of these innovations is discussed in the context of the health care reform stories. The paper discusses the variety of interactions between new governance and the older systems and how they coexist. It describes three ways in which the older processes are maintained, or could be maintained while utilizing the newer more effective processes. One type is the dynamic interaction between the old and new, a second is orchestrating a multi-pronged strategy that incorporates new governance techniques with more traditional incentives. The third interaction is the integration of traditional legal values, such as transparency, inclusion, and equity into the new processes.2

La gouvernance multiniveau et la nouvelle gestion publique : des idées nouvelles à intégrer aux approches traditionnelles du fédéralisme dans le contexte de l’étude des relations intergouvernementales

“…Aux États-Unis, une vision plus large du fédéralisme et des relations intergouvernementales, proche de celle de la GMN, est de plus en plus adoptée et soutenue par les chercheurs des domaines de l'administration et la gestion publiques (Kettl, 2000 ;Hoflund et Farquhar, 2008), du droit (Trubek, 2006 ;Blum, 2008) …”

“…De plus, elle note que la décentralisation déplace les pouvoirs vers les ordres inférieurs de gouvernement et réduit l'accent mis sur les programmes inflexibles administrés à l'échelle nationale. Il existe une interaction multiniveau au sein de laquelle le gouvernement national fixe les standards ou fournit le financement accompagné d'un lien entre les ordres de gouvernement fédéral, étatiques et municipaux (Trubek, 2006). S'agissant de l'élargissement horizontal de la gouvernance, Trubek considère les PPP et le recours à la négociation par les réseaux comme des attributs de la « nouvelle gouvernance ».…”

“…Les nouveaux espaces collaboratifs dans lesquels les parties prenantes sont engagées pour régler des problématiques concernant les soins de santé constituent l'un de ces exemples. Ces espaces peuvent être des réseaux collaboratifs de contrôle de la qualité, des groupes de technologie locaux et des planifications de groupe pour mettre en commun les régimes de couverture publics et privés (Trubek, 2006). Les réseaux collaboratifs sont institués aux éche-lons local, national et étatique.…”

Regulatory innovation in the governance of human subjects research: A cautionary tale and some modest proposals

“…At first glance, an IRB appears to ''proceduralize'' regulation, substituting forms of democratic deliberation for state command and control (Black 2000(Black , 2001. Consistent with contemporary prescriptions for ''new governance,'' it experiments with a new regulatory institution constituted of community stakeholders that fashion local norms and practices under the supportive, but distant, gaze of the state (Lobel 2004;Trubek 2006). Using an IRB to articulate ethical norms for local researchers is an idea that might have been taken straight from Habermas' discourse theory (Habermas 1996).…”

Hybrid design, systemic rigidity: Institutional dynamics in human research oversight

“…For proponents of regulatory responsiveness, a principal strategy for diffusing authority has been to engage a full range of potential policy actors. As mentioned earlier, virtually all proponents of new governance seek to promote innovation and flexibility through broadened participation in regulatory decision making (Lobel 2004; Trubek 2006). In one of the earliest new governance approaches, Ayres and Braithwaite (1992) envision negotiation between regulators and the regulated over a full range of oversight issues: the design of monitoring, oversight standards, the relation between violations and sanctions, and conditions of enforcement.…”