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Beth Duff-Brown
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The GOP’s proposed American Health Care Act may have gone down in flames, but health policy experts say there are plenty of other health-care reforms the Trump administration may attempt.

Michelle Mello and David Studdert, both professors at Stanford University School of Medicine and Stanford Law School and core faculty members at Stanford Health Policy, say medical malpractice reform, for one, is back on the federal policy agenda.

The two write in this New England Journal of Medicine commentary that Secretary of Health and Human Services Tom Price, an orthopedic surgeon and Republican congressman from Georgia before he was appointed to the Trump administration, sponsored several bills aimed at limiting medical liability.

House Speaker Paul Ryan and Price have both said medical malpractice is in crisis, with frivolous lawsuits driving up malpractice insurance premiums and forcing physicians out of business. Hospitals and doctors are so afraid of being sued they overprescribe costly tests and treatments, driving up the cost of health care.

But according to a study published last year, medical errors are the third leading cause of death in the United States. And those who follow medical malpractice insurance say the industry has stabilized in the last decade.

Mello and Studdert write that medical malpractice reform is worth pursuing. The liability system has a host of well-documented problems and its reform was omitted from the Affordable Care Act.  But, they argue, Republican proposals tilt too far towards protecting physicians, with harmful consequences for patients.

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“Two of the key reforms measures on the Republican agenda — ‘safe harbors’ for physicians who comply with clinical practice guidelines and the adjudication of medical injury disputes by expert panels — are promising ideas that have received a good deal of attention in the academic literature over the last 20 years,” Studdert said.

“However, design details matter,” he said. “The versions currently being considered in Congress are quite unconventional; they look more like physician-protection initiatives than reforms designed to improve safety or protect the interests of patients in other ways.” 

The “safe harbors” from liability for providers who adhere to clinical practice guidelines would involve the establishment of tribunals of medical experts who would decide malpractice claims. Price has also proposed “administrative health-care tribunals” that would be presided over by special judges with health care expertise and would issue binding rulings aided by testimony from independent experts.

One worrisome aspect of the Republican proposals is that they would replace ordinary standards of evidence with a requirement that patients prove “gross negligence.” 

“That means that if your physician was merely careless or unskilled, you’re out of luck as a plaintiff,” Mello explained. “You have to show something akin to willful and wanton misconduct — like the case in Boston where the surgeon left in the middle of an operation to deposit money in his bank.”

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Mello and Studdert, with their colleague Allen Kachalia at Harvard Medical School and Brigham and Women’s Hospital, note many observers find it an odd time for Congress to be considering malpractice reform, as the industry is stable and the incidence of paid claims has shrunk by half in the last decade. Indemnity-payment levels have declined or plateaued and many physicians pay less for liability insurance than they did a decade ago.

Price has claimed that defensive medicine is responsible for a quarter of U.S. health-care spending, about $650 billion, but the authors’ best estimates are closer to $50 billion.

Yet, in their commentary, the authors say this could be an ideal time to pursue reform, which ordinarily rises on the policy agenda only when a “malpractice crisis” occurs and liability insurance costs spike.  “When acutely stressed providers are clamoring for 
immediate relief, cool-headed policy deliberation rarely ensues,” they wrote. 


But, they add, reforms must be fair to patients as well as providers. They note that Price articulated a vision of health system reform that puts patients’ needs front and center.

“Medical liability reform needs the same vision,” they said.

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Senior Research Scholar, Columbia University’s School for International and Public Affairs
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Jason Healey is a Senior Research Scholar and adjunct faculty at Columbia University’s School for International and Public Affairs specializing in cyber conflict, competition and cooperation. Prior to this, he was the founding director of the Cyber Statecraft Initiative of the Atlantic Council where he remains a Senior Fellow.  He is the author of dozens of published articles and the editor of the first history of conflict in cyberspace, A Fierce Domain: Cyber Conflict, 1986 to 2012.  A frequent speaker on these issues, he is rated as a “top-rated” speaker for the RSA Conference and won the inaugural “Best of Briefing Award” at Black Hat.

During his time in the White House, he was a director for cyber policy and helped advise the President and coordinate US efforts to secure US cyberspace and critical infrastructure.  He created the first cyber incident response team for Goldman Sachs and later oversaw the bank’s crisis management and business continuity in Hong Kong.  He has been vice chairman of the FS-ISAC (the information sharing and security organization for the finance sector) and started his career as a US Air Force intelligence officer with jobs at the Pentagon and National Security Agency.  Jason was a founding member (plankowner) of the first cyber command in the world, the Joint Task Force for Computer Network Defense, in 1998, where he was one of the early pioneers of cyber threat intelligence.

He is on the Defense Science Board task force on cyber deterrence and is a frequent speaker at the main hacker and security conferences, including Black Hat, RSA, and DEF CON, for which he is also on the review board.  He is president of the Cyber Conflict Studies Association, and has been adjunct faculty at NSA’s National Cryptologic School, Georgetown University and Johns Hopkins School of Advanced International Studies. 

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The Japan Program at Stanford’s Shorenstein Asia-Pacific Research Center (APARC), with the generous support of the United States-Japan Foundation and Japan Society for the Promotion of Science, held a conference in November 2016 titled “Womenomics, the Workplace, and Women.” The report, which is an outcome of the conference, offers an analysis of the state of women’s leadership and work-life balance in Japan and the United States, and specific actions that Japanese government stakeholders, corporations, start-ups, and educational institutions can take to address gender inequality in Japan.

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Japan Program at the Shorenstein Asia-Pacific Research Center
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Abstract:

Within the last fifteen years, nine multilateral development banks (MDBs) have established internal accountability offices (IAOs).  These IAOs, the most well-known of which is the World Bank Inspection Panel, allow communities within borrowing states to bring complaints against MDBs if loan programs cause them harm and violate MDB policies.  The IAOs have been touted as effective fire-alarm mechanisms and remedies to the democratic deficit problem; they have also been criticized as broadly ineffective and toothless.  What explains the variation in IAO impact and efficacy?  I argue that borrowing states significantly constrain the impact of MDB IAOs and that borrowing state influence varies depending on regime type.  Democratic borrowing states will be more willing to absorb the potential costs associated with MDB IAOs—including program changes and possible program termination—than will autocratic states.  The argument is supported with quantitative evidence from a new dataset of all complaints filed through 2015.

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erica gould
Erica Gould is the Director of the International Relations Honors Program at Stanford University. She teaches courses on honors thesis writing, international political economy and international organizations.  She has taught previously at the University of Virginia and Johns Hopkins University.  Dr. Gould’s research has centered mainly around the question of how international organizations are controlled.  She is currently working on a project concerning international organizational decision-making rules and also one on the accountability mechanisms associated with international organizations.  Her publications include Money Talks: The International Monetary Fund, Conditionality and Supplementary Financiers (Stanford University Press, 2006), as well as articles in academic journals and several edited volumes. In addition to her research and teaching, Dr. Gould serves on the Board of Accountability Counsel, an international NGO based in San Francisco.  She received her PhD in Political Science from Stanford University and her BA from Cornell University.

Erica Gould Director of the International Honors Program at Stanford University
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When a state is “shamed” by outsiders for perceived injustices, it often proves counterproductive, resulting in worse behavior and civil rights violations, a Stanford researcher has found.

Rochelle Terman, a political scientist and postdoctoral fellow at Stanford’s Center for International Security and Cooperation (CISAC), recently spoke about how countries criticized by outsiders on issues like human rights typically respond -- and it's contrary to conventional wisdom. Terman has published findings, “The Relational Politics of Shame: Evidence from the Universal Periodic Review,” on this topic in the Review of International Organizations. She discussed her research in the interview below:

What does your research show about state "shaming"?

Shaming is a ubiquitous strategy to promote international human rights. A key contention in the literature on international norms is that transnational advocacy networks can pressure states into adopting international norms by shaming them – condemning violations and urging reform. The idea is that shaming undermines a state’s legitimacy, which then incentivizes elites into complying with international norms.

In contrast, my work shows that shaming can be counterproductive, encouraging leaders in the target state to persist or “double down” on violations. That is because shaming is seen as illegitimate foreign intervention that threatens a state’s sovereignty and independence.  When viewed in this light, leaders are rewarded for standing up to such pressure and defending the nation against perceived domination. Meanwhile, leaders who “give in” have their political legitimacy undermined at home. The result is that violations tend to persist or even exacerbate.

When and where does it work better to directly confront a country’s leadership about such injustices?

At least two factors moderate the effects of international shaming. The first is the degree to which the norm being promoted is shared between the “shamer” and the target. For instance, the West may shame Uganda or Nigeria for violating LGBT rights. But if Uganda and Nigeria do not accept the “LGBT rights” norm, and refuse to accept that homophobia constitutes bad behavior, then shaming will fail. In this case, it is more likely that shaming will be viewed as illegitimate meddling by foreign powers, and will be met with indignation and defiance.

Second, shaming is quintessentially a relational process. Insofar as it is successful, shaming persuades actors to voluntary change their behavior in order to maintain valued social relationships. In the absence of such relationship, shaming will fail. This is especially so when pressure emanates from a current or historical geopolitical adversary. In this later scenario, not only will shaming fail to work, it will likely provoke defensive hostility and defiance, having a counterproductive effect.

Combing these insights, we can say that shaming is most likely to work under two conditions: when the target is a strong ally, and the norm is shared.

What are some well-known cases where "shaming" backfired?

The main example I use in my forthcoming paper is on the infamous “anti-homosexuality bill” in Uganda. When Uganda introduced the legislation in 2009 (which in some versions applied capital punishment to offenders) it provoked harsh condemnation among its foreign allies, especially in the West. Western donor countries even suspended aid in attempt to push Yoweri Musaveni’s government to abandon the bill. According to conventional accounts, the onslaught of foreign shaming, coupled with the threat of aid cuts and other material sanctions, should have worked best in the Uganda case.

And yet what we saw was the opposite. The wave of international attention provoked an outraged and defiant reaction among the Ugandan population, turning the bill into a symbol of national sovereignty and self-determination in the face of abusive Western bullying. This reaction energized Ugandan elites to champion the bill in order to reap the political rewards at home. Indeed, the bill was the first to pass unanimously in the Ugandan legislature since the end of military rule in 1999. Museveni – who by all accounts preferred a more moderate solution to the crisis – was backed into a corner.

A Foreign Policy story quoted Ugandan journalist Andrew Mwenda as saying, “the mere fact that Obama threatened Museveni publicly is the very reason he chose to go ahead and sign the bill.” And Museveni did so in a particularly defiant fashion, “with the full witness of the international media to demonstrate Uganda’s independence in the face of Western pressure and provocation.”

Uganda anti-homosexuality law was finally quashed by its constitutional court, which ruled the act invalid because it was not passed with the required quorum. By dismissing the law on procedural grounds, Museveni – widely thought to have control over the court – was able to kill the legislation “without appearing to cave in to foreign pressure.” But by that time, defiance had already transformed Uganda’s normative order, entrenching homophobia into its national identity.

Does this 'doubling down' effect vary in domestic or international contexts?

Probably. States with a significant populist contingent, for instance, are especially hostile to international pressure, especially when it emanates from a historical adversary, like a former colonial power. Ironically, democracies may also be more susceptible to defiance, because elites are more beholden to their constituents, and thus are less able to “give in” to foreign pressure without undermining their own political power. 

The international context matters a great deal as well. States are more likely to resist certain norms if they have allies who feel the same way. For instance, we see significant polarization around LGBT rights at the international level, with most states in Africa and the Muslim world voting against resolutions that push LGBT rights forward. South Africa – originally a pioneer for LGBT rights – has changed its position following criticism from its regional neighbors. 

Does elite reaction drive this response to state "shaming?"

To be quite honest, this is a question I’m still exploring and I don’t have a very clear answer. My hunch at the moment is no. The “defiant” reaction occurs mainly at the level of public audiences, which then incentives elites to violate norms for political gain.  These audiences can be at either the domestic or international level. For instance, if domestic constituents are indignant by foreign shaming, elites are incentivized to “double down,” or at least remain silent, lest they undermine their own political legitimacy.

That said, elites can also strategize and manipulate these expected public reactions for their own political purposes. For instance, if Vladimir Putin knows that the Russian public will grow indignant following Western shaming, he might strategically promote a law that he knows will provoke such a reaction in order to benefit from the ensuing conflict. This is what likely occurred with Russia’s “anti-gay propaganda” law, which (unsurprisingly) provoked harsh condemnation from the West and probably bolstered Putin’s domestic popularity.

Any other important points to highlight?

One important point I’d like to highlight is the long-term effects of defiance. In an effort to resist international pressure, states take action that, in the long term, work to internalize oppositional norms in their national identity. In this way, shaming actually produces deviance, not the other way around.

Follow CISAC at @StanfordCISAC and  www.facebook.com/StanfordCISAC

MEDIA CONTACTS:

Rochelle Terman, Center for International Security and Cooperation: (650) 721-1378, rterman@stanford.edu,

Clifton B. Parker, Center for International Security and Cooperation: (650) 725-6488, cbparker@stanford.edu

 
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Protestors march to the United Nations building during International Human Rights Day in 2012 in New York City. Activists then called for immediate action by the UN and world governments to pressure China to loosen its control over Tibet -- a form of "state shaming," as examined by CISAC fellow Rochelle Terman in her research.
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zeynep tufekci1
Zeynep Tufekci, a contributing opinion writer for The New York Times, writes about the social impacts of technology. She is an assistant professor in the School of Information and Library Science at the University of North Carolina, a faculty associate at the Berkman Center for Internet and Society at Harvard, and a former fellow at the Center for Internet Technology Policy at Princeton. Her research revolves around politics, civics, movements, privacy and surveillance, as well as data and algorithms. Originally from Turkey, Ms. Tufekci was a computer programmer by profession and academic training before turning her focus to the impact of technology on society and social change. She switched to social science, and started calling herself a “technosociologist.” She has been published widely on the interaction of new technologies with society, politics and culture. Her forthcoming book from Yale University Press is tentatively titled “Beautiful Tear Gas: The Ecstatic, Fragile Politics of Networked Protest in the 21st Century.”

Zeynep Tufekci Writer for The New York Times
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How do autocrats manipulate the beliefs of their citizens during political crises? We argue that they cultivate a reputation for neutrality so that, during moments of crisis, their pro-regime arguments have some measure of credibility. To test the argument, we employ a corpus of 24 state-affiliated newspapers from Africa and Asia. Using a differences-in-differences estimation strategy, we find that propaganda in autocracies is generally indistinguishable from state-affiliated newspapers in democracies, save for the 15 days prior to an election, when positive coverage of the autocrat and the ruling party triples. This increase, we show, is driven not by more effusive articles, but an increase in the share of articles about the regime. Consequently, the aggregate volume of pro-regime coverage increases, but per article positive coverage does not. We find no evidence that autocrats employ propaganda to issue threats of repression during election seasons, and that their propaganda apparatuses generally avoid defaming the opposition. State-affiliated newspapers in democracies -- much like their autocratic counterparts outside of election seasons -- exhibit generally neutral coverage.

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carter brett
Dr. Brett Carter is an Assistant Professor at the School of International Relations at the University of Southern California and co-PI of the Lab on Non-Democratic Politics. He holds a Ph.D. from Harvard University, where he was a Graduate Fellow at the Harvard Academy for International and Area Studies. He was previously a fellow at Stanford University's Center on Democracy, Development, and the Rule of Law, as well as the Hoover Institution. His research focuses on autocratic politics in the Information Age. He is currently working on three book projects: one on autocratic survival in Post-Cold War Africa, one on autocratic propaganda, and one that exploits the Foreign Agents Registration Act to explore the role of autocratic money in American politics.
 
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Brett Carter is an Associate Professor in the Department of Political Science and International Relations at the University of Southern California, a Hoover Fellow at Stanford University's Hoover Institution, and a Faculty Affiliate at Stanford's Center on Democracy, Development and the Rule of Law. He received a Ph.D. from Harvard University, where he was a fellow at the Harvard Academy for International and Area Studies.

Carter studies politics in the world's autocracies. His first book, Propaganda in Autocracies: Institutions, Information, and the Politics of Belief (Cambridge University Press), draws on the largest archive of state propaganda ever assembled — encompassing over eight million newspaper articles in six languages from nearly 60 countries around the world — to show how political institutions shape the propaganda strategies of repressive governments. It received the William Riker Prize for the Best Book in Political Economy, the International Journal of Press/Politics Hazel Gaudet-Erskine Best Book Award, Honorable Mention for the Gregory Luebbert Award for the Best Book in Comparative Politics, and Honorable Mention for the APSA Democracy & Autocracy Section's Best Book Award.

His second book, in progress, shows how politics in Africa’s autocracies changed after the fall of the Berlin Wall and how a new era of geopolitical competition — marked by the rise of China and the resurgence of Russia — is changing them again.

Carter’s other work has appeared in the Journal of Politics, British Journal of Political Science, Perspectives on Politics, Journal of Conflict Resolution, Security Studies, China Quarterly, Journal of Democracy, and Foreign Affairs, among others. His work has been featured by The New York Times, The Economist, The National Interest, and NPR’s Radiolab.

Hoover Fellow
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CDDRL Visiting Scholar, 2020-2021
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Assistant Professor at the School of International Relations at the University of Southern California
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Expected dramatic shifts of foreign policy by leading democracies, including the U.S. and U.K., would shake a future of liberal international order, which has underpinned the stability even after the end of the Cold War. Since Mr. Donald Trump was elected as the 45th President of the U.S., abovementioned discourse is heard everywhere in Europe and Asia today.

It is not clear, if American leadership and military presence would in fact retreat, how American allies behave and whether they can work together to sustain the order. Among others, Japan has been the exceptionally strong believer of such postwar American leadership. It is doubtful that all American allies and friends share same views, having their own historical context with the U.S. and own ideas on order and principles. Hence, naturally they shall differ in losing the confidence on the durability of American leadership.

A new order will be shaped by many factors, but American allies’ perspectives should not be overlooked. Hegemon’s own reluctance for ruling is surely significant. So is other great power’s revisionism, making use of such strategic opportunities. However, American allies has the potential to shape the fate of the order: if they succeed in acting collectively, it shall underpin the global governance for a while, and ensue the order transformation process in rather slow and peaceful pace. 

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If they fail, it shall not only accelerate the U.S. retrenchment, but invite an emergence of divisive and competitive order. Sahashi shares the findings from the international study project which he leads, and argues the difficulty for US allies to unite themselves and the potential order transformation in the long term.

Ryo Sahashi is Associate Professor of International Politics and Director, Faculty of Law, Kanagawa University, Yokohama, and is leading the newly-launched international joint study “Worldviews on the United States.” From 2014-2015, he served as Visiting Associate Professor, Shorenstein APARC, Stanford University.

 

Ryo Sahashi Associate Professor, Kanagawa University
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dsc 0004 bai jing sayuri
Dr. Sayuri SHIRAI is currently a professor of Keio University and is also a visiting scholar at the Asian Development Bank Institute. She was a Member of the Policy Board of the Bank of Japan (BOJ) from April 2011 to March 2016, who is responsible for making policy decisions. She also taught at Sciences Po in Paris in 2007–2008 and was an economist at the International Monetary Fund (IMF) from 1993 to 1998.

She is the author of numerous books on a variety of subjects including the People’s Republic of China’s exchange rate system, Japan’s macroeconomic policy, IMF policy, and the European debt crisis. Her most recent book (translated title: Unwinding Super-Easy Monetary Policy), published in August 2016, is about the monetary policies of the BOJ, the European Central Bank, and the Federal Reserve System. She regularly appears on CNBC, Bloomberg, Reuters, BBC, and features in many Japanese TV programs and newspapers, commenting on the Japanese economy and monetary policy. URL: http://www.sayurishirai.jp

Her most recent book in English is Mission Incomplete: Reflating Japan’s Economy published by the Asian Development Bank Institute in February 2017. It is a complete analysis of BOJ’s unconventional monetary easing from the late 1990s to the present. Free Download is available at https://www.adb.org/publications/mission-incomplete-reflating-japan-economy.

Sayuri Shirai Professor at Keio University and Visiting Scholar at Asian Development Bank Institute
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Abstract:

One policy option for countries reliant on natural resources is to share part of the revenues directly with citizens, an idea known as oil to cash. Technological innovation, such as biometric identification and mobile money, now allow direct payments to people on a massive scale. Additional changes in the global marketplace, experiments in India and Kenya, and shifting political views of cash transfers have all affected the potential of cash to boost governance.

 

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todd moss
Todd Moss is senior fellow at the Center for Global Development in Washington DC and nonresident scholar at the Center for Energy Studies at Rice University’s Baker Institute. A former Deputy Assistant Secretary of State, Moss is the author of Oil to Cash: Fighting the Resource Curse with Cash Transfers and The Golden Hour, a diplomatic thriller set in West Africa.

Todd Moss Senior fellow at the Center for Global Development in Washington DC
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