Fox Daniel M
Milbank Memorial Fund.
Milbank Q. 2015 Mar;93(1):179-210. doi: 10.1111/1468-0009.12109.
POLICY POINTS: Health policy in the United States has, for more than a century, simultaneously and paradoxically incentivized the growth as well as the commercialization of nonprofit organizations in the health sector. This policy paradox persists during the implementation of the Affordable Care Act of 2010.
For more than a century, policy in the United States has incentivized both expansion in the number and size of tax-exempt nonprofit organizations in the health sector and their commercialization. The implementation of the Affordable Care Act of 2010 (ACA) began yet another chapter in the history of this policy paradox.
This article explores the origin and persistence of the paradox using what many scholars call "interpretive social science." This methodology prioritizes history and contingency over formal theory and methods in order to present coherent and plausible narratives of events and explanations for them. These narratives are grounded in documents generated by participants in particular events, as well as conversations with them, observing them in action, and analysis of pertinent secondary sources. The methodology achieves validity and reliability by gathering information from multiple sources and making disciplined judgments about its coherence and correspondence with reality.
A paradox with deep historical roots persists as a result of consensus about its value for both population health and the revenue of individuals and organizations in the health sector. Participants in this consensus include leaders of governance who have disagreed about many other issues. The paradox persists because of assumptions about the burden of disease and how to address it, as well as about the effects of biomedical science that is translated into professional education, practice, and the organization of services for the prevention, diagnosis, treatment, and management of illness.
The policy paradox that has incentivized the growth and commercialization of nonprofits in the health sector since the late 19th century remains influential in health policy, especially for the allocation of resources. However, aspects of the implementation of the ACA may constrain some of the effects of the paradox.
政策要点：一个多世纪以来，美国的卫生政策自相矛盾地同时激励了卫生部门非营利组织的发展及其商业化。在2010年《平价医疗法案》的实施过程中，这一政策悖论依然存在。
一个多世纪以来，美国的政策既激励了卫生部门免税非营利组织数量和规模的扩张，也推动了它们的商业化。2010年《平价医疗法案》（ACA）的实施开启了这一政策悖论历史的新篇章。
本文运用许多学者所称的“解释性社会科学”来探究这一悖论的起源和持续性。这种方法将历史和偶然性置于形式理论和方法之上，以便呈现连贯且合理的事件叙述及其解释。这些叙述基于特定事件参与者生成的文件，以及与他们的对话、对其行动的观察和对相关二手资料的分析。该方法通过从多个来源收集信息，并对其连贯性和与现实的相符性做出严谨判断来实现有效性和可靠性。
由于对其对人群健康以及卫生部门个人和组织收入的价值达成共识，一个有着深厚历史根源的悖论持续存在。参与这一共识的包括在许多其他问题上存在分歧的治理领导者。该悖论持续存在是因为对疾病负担及其应对方式的假设，以及对转化为专业教育、实践以及疾病预防、诊断、治疗和管理服务组织的生物医学科学影响的假设。
自19世纪末以来激励卫生部门非营利组织发展和商业化的政策悖论在卫生政策中仍然具有影响力，尤其是在资源分配方面。然而，《平价医疗法案》实施的一些方面可能会限制这一悖论的某些影响。
