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UK:NHS&Social Care Scandal の責任問題 [Social Policy]

前にイギリスのSocial Care の現状が人権侵害に当たるという批判を,このブログで紹介しましたが,その国の監督庁の責任者が,とうとう辞任に追い込まれました.

イギリスでは,NHS (hospitals)やSocial Care(care homes)でスキャンダルが生じた場合,国の監督庁の責任者まで責任が問われることを重ねてご紹介したいと思います.

原文のタイトルに,the Stafford hospital scandal とありますが,そこでは国営病院の1つ,Stafford hospital で,reviews had criticised "appalling" standards which were said to have caused needless deaths. と死亡率が異常な高さを示してその運営水準が問題になった2009年6月の時点では,NHS(国営医療サービス)の行政トップは,最初,統計のエラーの範囲だと強弁していたのです.

そのイギリスでいろいろな指摘を踏まえて,2009年4月に,the Care Quality Commission を創設し,Care Quality の監視を強化した矢先にこのScandal がBBC(国営テレビ)によって報道されたのです.

そのトップに就任したのが Cynthia Bower で,彼女は "She has years of experience in both health and social care. She knows both sectors like the back of her hand. She is perfectly placed to lead our drive to improve services on behalf of patients and the public," とその適任性を強調されたのですが,her failure, in her previous job as a senior NHS boss, to respond vigorously enough to the emerging evidence about appalling care at Stafford hospital having caused or contributed to dozens – hundreds, it was later confirmed – of patients' deaths. が厳しく批判されたのです.

Andrew Lansley, the then shadow health secretary, said at the time: "We have to ask whether it is right that the person in charge of the West Midlands strategic health authority at the time, Cynthia Bower, is now to be put in charge of the national regulator which heads up these investigations and which will be responsible for ensuring that this never happens again in Mid Staffordshire or elsewhere."

さらに決定的だったことは,公聴会の行方です.The findings of the year-long public inquiry into how repeated regulatory failure allowed the situation at Stafford to continue, expected in June or July, are unlikely to be kind to Bower, given the evidence presented to the chair, Robert Francis QC. More immediately, a forthcoming report from the Commons public accounts committee into the CQC is expected to be "damning" of the organisation and scathing about Bower's leadership skills.
下院のpublic accounts committee の報告も,Bower には厳しいものになると予想されたのです.

そこで,そうした厳しい報告が出る前に,Bower は辞任したという経緯です.予想される報告の後には,Bower に連なる一連の責任者にも責任追及が及ぶに違いありません.

翻って,わが国では,そうした厳しい行政ないし管理責任が問われることが極めて稀だという所に日本の政治と行政の無責任体質が蔓延していると思えてなりません.

副島原発で3つものメルトダウンが生じても,カラ菅さんが目処が立つまで...と何時までも居座ったのは,わが国の政治,行政,民間の無責任体制をいっそう増長したと思えてならないのです.

 

  

 

Cynthia Bower never escaped the shadow of the Stafford hospital scandal

The Care Quality Commission's departing chief was undermined by a light-touch approach and accusations of complacency

Stafford hospital
Stafford hospital's high death rate was dismissed as a statistical blip by the strategic health authority then run by Cynthia Bower. Photograph: Christopher Furlong/Getty Images

One of the Care Quality Commission's first acts after its creation in April 2009 was to defend Cynthia Bower's suitability as its chief executive. "She has years of experience in both health and social care. She knows both sectors like the back of her hand. She is perfectly placed to lead our drive to improve services on behalf of patients and the public," the regulator said.

That was in response to mounting pressure over what critics said was her failure, in her previous job as a senior NHS boss, to respond vigorously enough to the emerging evidence about appalling care at Stafford hospital having caused or contributed to dozens – hundreds, it was later confirmed – of patients' deaths.

Stafford, the biggest healthcare scandal of modern times, has hung like a dark cloud over Bower ever since, even before the CQC became embroiled in claims, inquiries and Whitehall intrigue over its many alleged failings. Andrew Lansley, the then shadow health secretary, said at the time: "We have to ask whether it is right that the person in charge of the West Midlands strategic health authority at the time, Cynthia Bower, is now to be put in charge of the national regulator which heads up these investigations and which will be responsible for ensuring that this never happens again in Mid Staffordshire or elsewhere."

The findings of the year-long public inquiry into how repeated regulatory failure allowed the situation at Stafford to continue, expected in June or July, are unlikely to be kind to Bower, given the evidence presented to the chair, Robert Francis QC. More immediately, a forthcoming report from the Commons public accounts committee into the CQC is expected to be "damning" of the organisation and scathing about Bower's leadership skills. "The MPs were considering whether or not they should ask for her to go in the report, which would be extraordinary if it happened – a parliamentary committee demanding that," said a source familiar with the committee's deliberations.

In theory Bower's background made her an ideal candidate to head the CQC. "She's a very caring, thoughtful, sensitive person who cares passionately about health and social care and gives over 100% to everything she's doing," says a friend, who is a senior figure in the NHS. "She's a loss to health and social care. While I think she was partly a victim of circumstances – the CQC was asked to do too much too quickly – I also think she demonstrated poor leadership by letting the CQC be too 'light-touch' and not robust enough from the start in its inspection of hospitals and care homes."

Bower spent the first 19 years of her career working in and managing children's homes before joining the NHS in 1995 as a policy officer at Birmingham health authority. She went on to work in leadership roles for a variety of NHS organisations in the West Midlands, before becoming chief executive of the region's strategic health authority (SHA) in 2006.

During that time evidence began to emerge about serious failings in patient care at Stafford. But her SHA rejected the alarmingly high death rates as a statistical blip. She later admitted that Stafford "wasn't on my radar" during her time at the SHA. Julie Bailey, founder of Cure the NHS, the campaign group that was formed in the wake of the patient deaths, is one of Bower's most trenchant critics for what she says was the departing CQC boss's fatal inaction and complacency then.

"I have spent my entire professional life thinking about how the most vulnerable people can get the best service," Bower told the Guardian in 2009. She also talked in that interview about the "strong moral values" she inherited from her sub-postmaster father and mother, both Christians, when she was growing up in a mining area near Worksop, Nottinghamshire.

However, it was the CQC's failure to properly ensure that the welfare of vulnerable people it was meant to be protecting – elderly hospital patients, care home residents, people with learning disabilities – was being upheld that damaged the regulator's credibility and raised serious questions in the Department of Health, the NHS and the social care world about Bower's abilities and judgement. There was amazement inside the CQC when she wound up its highly respected 20-strong central investigations team, which – while working for the Healthcare Commission, one of the CQC's predecessor bodies – had uncovered scandals at Stafford, the Maidstone and Tunbridge Wells hospital trust and elsewhere.

One ex-colleague says: "We were even banned from using the word 'investigation', even though we were the regulator – it was bizarre." In retrospect, her downfall was probably inevitable when key organisations in both the NHS and social care began to complain that their premises, which depend on trust and quality care, were not being inspected enough.

Critics pointed out that it was the BBC's Panorama programme that exposed the scandal at Winterbourne View hospital for people with learning disabilities, not the CQC, which ignored a whistleblower who approached them with his concerns. And the sometimes shocking treatment of elderly people, both in hospital and in care homes, was highlighted by the NHS ombudsman, Age UK and the Patients Association – again, not the regulator.

She clearly regrets the CQC not being more robust from the outset. "We came in with a very light touch, risk-based notion of regulation and I think that one of the things we've heard – both from our own staff but also from the public – is that they want inspectors on wards, greeting patients, talking to frontline staff, observing care. Where people's lives and wellbeing are at stake [the public] don't want to hear about light-touch regulation," she admitted to the Health Service Journal last July.

Friends say she was hampered from the start by the regulator's remit – too wide, even critics agreed – lack of resources, such as a Whitehall-ordered recruitment freeze meaning it could not hire more than 100 inspectors, and the fact that the CQC's budget was less than the combined funding of its three predecessors. Even reports that took the regulator to task for various failings acknowledged that these limitations did restrict its effectiveness.

In the past year the CQC has switched tactics – partly because Lansley made it clear he was dissatisfied – and, arguably too late, begun undertaking unannounced inspections and promising that every hospital would be inspected every year. But the change was too little to reassure her critics or restore her authority or credibility.

Her departure, the likely findings of the Stafford hospital public inquiry, and disclosures about poor care in both health and social care settings, have prompted Lansley and his department – reluctantly but of necessity – to consider if a new system of regulation is now necessary, to avoid the same mistakes being made again.

 

Public inquiry into scandal-hit Stafford Hospital

 

The problems at Stafford - run by the Mid Staffordshire NHS Trust - were laid bare by the NHS regulator in March 2009.

The Healthcare Commission reported there had been at least 400 more deaths than expected between 2005 and 2008.

It cited a catalogue of poor standards, including cases where receptionists had been used to assess emergency patients.

But this was just one of a long-line of reviews.

These included an independent inquiry launched by the government. It was held in private and reported in February, saying the trust had become driven by targets and cost-cutting.

Campaigners believe the failings of Stafford go much further than one badly-run trust however.

The trust had been climbing the NHS ratings ladder during the period in question and was even given elite foundation trust status.

So earlier this year the Labour government set up a further inquiry looking at the role of the wider regulatory agencies, but this was not enough for campaigners.

They demanded a more wide-ranging probe which had tougher powers. A public inquiry is held in open and is able to compel witnesses attend hearings and cross examine them.

Mr Lansley said: "We know only too well what happened at Mid-Staffordshire, in all its harrowing detail, and the failings of the trust itself.

"But we are still little closer to understanding how it was allowed to happen by the wider system.

"The families of those patients who suffered so dreadfully deserve to know.

"And so too does every NHS patient in this country.

Andrew Lansley: 'Public hearing is only way to combat a culture of secrecy'

"This was a failure of the trust first and foremost, but it was also a national failure of the regulatory and supervisory system who should have secured the quality and safety of patient care."

The inquiry will be chaired by Robert Francis QC who had led the government inquiry and was asked to do the same for the follow up one.

Mr Lansley said he did not want Mr Francis to go over the ground already covered, but focus instead on how the culture in the NHS allowed this to happen.

The final report is expected in March 2011.

The health secretary also said he wanted to strengthen the ability of staff to whistleblow.

He said he would be issuing guidance to trusts on their procedures as well as looking to introduce a contractual right for staff to raise concerns that are in the public interest.

Julie Bailey, founder of Cure the NHS, the campaign group set up by the families of victims, said: "A year ago David Cameron promised a public inquiry and he's kept that promise.

"The terms of reference and scope are just what we wanted.

"Former health ministers, Department of Health executives in Whitehall and in Stafordshire will now have to exlain why they did not stop this disaster."


UK:縮小するSocial Policy 教育ー日本は? [Social Policy]

事の発端は,イギリスでも労働党政権下で膨張してきた赤字国債の累積が,EURO圏諸国の経済危機の深刻さから,EURO加盟国ではないまでもEU加盟国であるイギリスにも大きな影を落とし始めたことにあります.

より直接的には,大多数の大学生が国の奨学金に依存してきたイギリスの大学生に,奨学金が大幅に減額されることが予定されています.
それは弱い学部,学科にまず強く影響しますから,Social Policy も大きな影響を受けると予測されているのです.

流れの先を行って,まず,中身が固まっていなかった the Social Policy and Social Work Subject Centre (SWAP) は早々と消滅しました.Social Work は,これまでにも書いた負の実績から,立場が弱かったのです

それに続いたのが,the Joint University Council Social Policy Committee (JUCSPC)の廃止と 実際に始まった the withdrawal of Social Policy teaching at some universities です.後者は取り分け有力Universities が先行しましたから,他の大学も一斉に浮き足立ってきたということがあります.

although the Higher Education Academy has retained one social work and social policy subject specialist, her capacity to support teaching and learning activities is very much reduced and therefore consideration is needed as to what the SPA(Social Policy Association=Social Policy 学会ーしかし,有資格者の参加率は54%弱ににとどまる) can do to complement this work.

以下は,このSPA が 消えゆくSWAPの委嘱を受けて行った調査結果です.

69 HEI(Higher Education Institutions) institutions offered degree courses that included some Social Policy teaching at undergraduate level, with 59 institutions offering Social Policy at postgraduate level.

.Single Honours Social Policy was available at just 16 HEIs for 2011/12.  Findings highlighted that Social Policy is today taught in a range of contexts, and is often incorporated within broader degree courses such as Social Sciences.
つまり,単独のSocial Policy は激減して,もっと幅広いdegree course で教えられるようになっている.

.most Social Policy teachers are making use of more traditional teaching methods such as lectures and seminars, there is evidence of a growth in the use of placements and online teaching methods within the subject area. Ensuring that teaching materials were up-to-date and current was seen as best practice in Social Policy teaching and learning.
Research-led teaching
was also generally considered to be one of the hallmarks of good practice, with research findings indicating that practices of research informing teaching varies across Social Policy teaching. The experiences of teachers within the subject are likely to be subject to significant changes in coming years.

.It seems there is a widespread expectation that undergraduate student numbers will decline and this will inevitably impact on other aspects of the teaching and learning experience. Indeed, 41.2% of respondents expect the number of undergraduate students studying Social Policy at their institution to fall in 2012.
With regard to postgraduate student numbers, the most common expectation from respondents was that postgraduate student numbers would stay the same in both 2012 and over the next five years.

,there is concern that in the future departments will be affected by redundancies, amalgamation with other departments and the withdrawal of courses.
In terms of departmental changes over the next two years, 20.1% of respondents thought that amalgamation with another department was quite or very likely, while only 4.5% thought that the closure of their department was either quite or very likely.
With regard to staff redundancies, a considerable proportion (9.3%) thought that redundancies in their department over the next two years is a very likely outcome, while 24.7% thought this was quite likely.
The possibility of programmes or courses being withdrawn from their department was also seen as a fairly common possibility, with 42.4% of respondents reporting that the withdrawal of programmes or courses from their department was either very or quite likely over the next two years.

要するに,学生数の減少を考えると,教員も過剰になる可能性が高く,コースの他との併合,ないし閉鎖もあり得るという見通しが,ある程度の広がりを見せているということです.

日本のSocial Policy & work 混交の中途半端な大学,学部,学科は,「税と社会保障の一体改革」というPolicy には,一部を除いて,今更参画する余地はないでしょうから,Policy では余剰になり,経験者を要するSocial Work では,Social Care を除けば,やはり過剰になるでしょう.
Social Care も移民受け入れに舵を切れば,評判の悪い日本スタッフは縮小を迫られるでしょう.

今,イギリスで起きている事態は,おそらく5年で日本の現実になるでしょうが,業務独占職の養成課程ではなく,名称独占の国家試験取得コースに過ぎない日本の大学,学部,学科は,まあ,過半数が淘汰の対照になるのではないでしょうか?

個別に名前を挙げるのは躊躇されますが,公的扶助ケースワーク志向や人口高齢化対策志向で方向を誤ってきた社会事業大学への国庫助成金は打ち切られるべきでしょう.
その点では,養成課程である保健師養成課程の国立大学学生定員が大幅削減されている現状は,それを想定する参考になるのではないでしょうか?

 

 

The Current and Future Status of Social Policy Teaching in UK HEIs


Executive summary

In a climate of significant reforms to student finance, it is important to generate baseline data regarding where and in what degree combinations Social Policy is currently taught in UK Higher Education Institutions (HEIs). A context which includes the demise of the Social Policy and Social Work Subject Centre (SWAP), the folding of the Joint University Council Social Policy Committee (JUCSPC), and the withdrawal of Social Policy teaching at some universities makes such a project particularly timely and pertinent.

This report details findings from a small-scale study designed to explore the teaching of Social Policy in UK HEIs, while also gathering information on experiences of teaching Social Policy, examples of good practice and the training / support needs of teachers themselves. The research project also generated attitudinal data regarding the future of the subject and perspectives on how best to safeguard Social Policy in these times of change. The project was commissioned by the SPA with funding provided by SWAP. The closure of SWAP was a particularly important factor behind the survey; although the Higher Education Academy has retained one social work and social policy subject specialist, her capacity to support teaching and learning activities is very much reduced and therefore consideration is needed as to what the SPA can do to complement this work.

The research consisted of three central components:
 an audit of the teaching of Social Policy capturing baseline data regarding which HEI institutions teach the subject at both undergraduate and postgraduate level
 an internet survey exploring experiences of teaching Social Policy and attitudes to the future of the subject given the changing context of student finance and government support
 three qualitative interviews with Social Policy lecturers to explore their experiences of teaching Social Policy and expectations of how the subject will fare during times of change

174 individuals responded to the survey which generated rich data on both teaching experiences and attitudes to the teaching of the subject. Notably, a majority of respondents (53.4%) were not currently members of the SPA suggesting real scope for further efforts to extend recruitment to those identifying themselves as teaching Social Policy who are not currently members of the learned society.

Data from the audit of Social Policy teaching found that 69 HEI institutions offered degree courses that included some Social Policy teaching at undergraduate level, with 59 institutions offering Social Policy at postgraduate level. Single Honours Social Policy was available at just 16 HEIs for 2011/12. From 2012/13, Single Honours Social Policy will no longer be taught at either Stirling University or London South Bank University, reducing the range of institutions where Single Honours Social Policy is available by 12.5%. Findings highlighted that Social Policy is today taught in a range of contexts, and is often incorporated within broader degree courses such as Social Sciences.

The internet survey and qualitative interviews offered insights into the experiences of Social Policy teachers in 2011, alongside considerations of what constitutes best practice within the subject. Findings suggested whilst most Social Policy teachers are making use of more traditional teaching methods such as lectures and seminars, there is evidence of a growth in the use of placements and online teaching methods within the subject area. Ensuring that teaching materials were up-to-date and current was seen as best practice in Social Policy teaching and learning. Whilst this was seen as challenging, updating materials regularly was common. Research-led teaching was also generally considered to be one of the hallmarks of good practice, with research findings indicating that practices of research informing teaching varies across Social Policy teaching. The experiences of teachers within the subject are likely to be subject to significant changes in coming years. This research provides a useful baseline against which to track such developments.

As part of the internet survey, respondents were asked about what tangible impacts they expected their department to experience as the changes to student finance are introduced in 2012. It seems there is a widespread expectation that undergraduate student numbers will decline and this will inevitably impact on other aspects of the teaching and learning experience. Indeed, 41.2% of respondents expect the number of undergraduate students studying Social Policy at their institution to fall in 2012. This contrasted with just 28.1% who thought student numbers would stay the same, and 1.9% who actually predicted that student numbers would increase. With regard to postgraduate student numbers, the most common expectation from respondents was that postgraduate student numbers would stay the same in both 2012 and over the next five years.

Findings from the internet survey also show that there is concern that in the future departments will be affected by redundancies, amalgamation with other departments and the withdrawal of courses. In terms of departmental changes over the next two years, 20.1% of respondents thought that amalgamation with another department was quite or very likely, while only 4.5% thought that the closure of their department was either quite or very likely. With regard to staff redundancies, a considerable proportion (9.3%) thought that redundancies in their department over the next two years is a very likely outcome, while 24.7% thought this was quite likely. The possibility of programmes or courses being withdrawn from their department was also seen as a fairly common possibility, with 42.4% of respondents reporting that the withdrawal of programmes or courses from their department was either very or quite likely over the next two years.

This research also explored ideas for how to best safeguard and protect Social Policy in times of uncertainty and against a backdrop of expected contractions in student numbers. Both the internet survey and qualitative interviews generated rich data on these themes, with particular attention paid to the role of the SPA in supporting Social Policy over the coming years. Survey respondents felt there was scope in efforts to market Social Policy more effectively in schools, while there was also seen to be potential in putting more emphasis on employability and offering more placements as part of degree and postgraduate courses. Importantly, the internet survey and audit uncovered pockets of good practice in terms of offering placements to students and placing emphasis on employability. A number of respondents highlighted the importance of attempts to increase awareness of Social Policy as a subject area, with work needed to make more explicit the close links between central contemporary issues such as welfare reform and public sector changes and the academic subject of Social Policy. Indeed, a significant number of respondents suggested that a key strength of Social Policy is its close alignment with the key issues of the day.

With regard to how best to support those already teaching Social Policy, a large majority of respondents (82.2%) said they would welcome the opportunity to share their experiences of teaching Social Policy with others. This is undoubtedly one area where the SPA could play a role by facilitating those teaching Social Policy coming together to reflect on their experiences and to discuss issues related to teaching and learning. Some survey respondents also suggested that the SPA might want to consider increasing its focus on teaching and learning issues more generally, a finding which in fact resonates closely with the SPA’s own priorities for the future.

As the reforms to student finance take effect, it will be critically important that the SPA and wider Social Policy community continue to monitor changes in the teaching of Social Policy, while also taking action to try and safeguard the subject area.


高齢者施設における高齢者虐待:監督責任問題 [Social Policy]

先日,私は「虚構の社会福祉士・介護福祉士制度を廃止すべき」というブログを書き,それがイギリスで,1978年に,Higgins から Poverty Business と定義して決めつけられた福祉系大学や研究調査機関を初めとする福祉ビジネスの増殖,質的低下を招いたと書きましたが,図らずもそれを実証する事例が報告されました.

関西の高齢者施設における介護福祉士による高齢者虐待事件です.虐待された高齢者には骨折まで生じていたといいます.

社会福祉士,介護福祉士国家試験制度が虚構に過ぎないことを実証して余りある出来事といえます.
もっとも,この問題は,最近始まった問題ではなく,既に虚構の実態が漏れ始めてから,高齢者虐待防止法が2006年に施行されていた事実から見ても,かなり根深い問題であることが分かります.

私が前にイギリスの児童虐待の最悪事件といわれる事件の処理経過をこのブログで追跡しましたが,そこから学ぶべき事は,今回の事件が,当該施設の経営・監督責任者の責任を放置している点です.こうした場合,イギリスの事件のブログで書いたように,公開の公聴会を開催して,直接の担当者ばかりでなく,所属機関や施設の運営のあり方の問題を含めて原因究明に当たるべきです.

施設内で起きた問題について,施設運営責任者が監督責任を負っていたはずで,直接手を下した職員を懲戒解雇すればそれで経営者責任が果たされたとして済むべきモノではないはずです.

同じ事は他の福祉施設にも当てはまりますから,児童福祉施設その他の施設で虐待や不慮の事件があった場合にも,その経営監督責任が,公開の公聴会で厳しく追及される仕組みを確立すべきです.

日本の社会福祉施設ないし,上記の定義に従えば増殖した大学を含む「貧困ビジネス」には,そもそも社会福祉法人,学校法人の名称のもとで実質的には家族経営が多すぎますが,それは,経営監督責任が厳しく問われてこなかったことが,公費中心に施設の増殖を進めながら,家族経営が連綿として存続することをを許してきた側面があったというべきでしょう.

福祉施設職員の離職率の高さがほとんど減ることはなく,今回の事件のように職員のモラルの低下が広がっていますが,そのひとつの背景には,閉鎖的な家族経営の多さがあると考えられてならないのです.


U.S. Worst in Child Abuse [Social Policy]

先にイギリスの史上最悪の児童虐待死についてリポートしましたが,UNICEF の統計では,イギリスは,先進国の中では虐待死の少ない方なのです.

下に,アメリカがworst だとする記事を紹介しますが,そこでは,According to UNICEF, the United States has 2.4 annual deaths per 100,000 children, compared to 1.4 for France; 1 in Japan, and 0.9 in the United Kingdom. とアメリカは図抜けて悪い数字になっています.

ただ,念のため,児童虐待に関する統計は信頼に値しないという議論を紹介しておきます.
By Jim Hopper, Child Abuse: Statistics, Research and Resources (last revised 1/12/2012)
からの引用です.

・・・When thinking about statistics on child abuse, it is helpful to know that the very idea of "child abuse" is historical development.

  • Only recently, and only in particular countries and cultures, has the abuse of children come to be seen as a major social problem and a main cause of many people's suffering and personal problems.

     

  • Of course children have been abused throughout human history. But for people to think about child abuse as we do now, to create legal definitions and government agencies that can remove children from their homes, and to conduct thousands of research studies on the effects of abuse - these are historically and culturally embedded developments.

・・・Statistics on rates of child abuse and neglect are controversial.

All statistics on the incidence and prevalence of child abuse and neglect are disputed by some experts. (Incidence refers to the number of new cases each year, and prevalence to the percentage of people in a population who have had such experiences.)

  • Why?

    • Complex and subtle scientific issues are involved in studies that generate these statistics.


      Even the most objective scientific research is imperfect. At least one or two methods used in any study must be chosen by researchers based on opinions and judgements, not just facts and logic. And even the objectively best methods available may still have limitations.


      For example, there are important controversies about how to define abuse and neglect. This is true for official government studies and any other research study.

    • The definitions of abuse used in official government studies are based on laws, because government definitions are needed for more than research purposes. They are also needed for purposes like determining whether or not suspected abuse should be reported, investigated, "substantiated" (as actually having occurred), and lead to action by a social service agency or court.

       

    • In contrast, independent researchers can use different definitions because they have different purposes than government agencies, like understanding the different effects of mild and extreme emotional, physical, and/or sexual abuse.

       

    • No matter what kind of study it is, small changes in definitions can result in big differences in statistics on abuse and neglect.

       

    • Another example: The number of questions a researcher asks research participants about possible sexual abuse experiences in childhood influences how many of those participants who were actually abused will remember and report it.
      • Memories are retrieved based on cues, and some people need more and different cues to than others remember similar experiences.

         

      • This is why, for example, large epidemiological studies with thousands of research subjects, but few questions asked, will always yield underestimates of abuse rates.

         

  • Some bottom lines:
    • Emotions and moral commitments influence everyone's reasoning and judgement to some extent.

       

    • Every scientific study, and every statistic, is partly a product of biases and imperfect methods.

       

    • Any experts who claim to be without bias are fooling themselves or trying to fool you.
  • いちいち訳しませんが,child abuse に関する調査や統計は,決してバイアス・フリーではあり得ないのだといっています.
    とりわけ,Sweden が先駆的に1979年に「親の児童に対する体罰禁止法」を立法化し,ドイツなど多くの国が追随したことの実際の効果を巡って,上のような様々な疑問が投げかけられているのです.イギリス,アメリカではそうした立法化は見られません.

    あとは,どうぞご自由にご渉猟下さい.

     

    U.S. Worst in Child Abuse

    Analysis by Benjamin Radford
    Mon Oct 24, 2011 09:53 AM ET

    Shoes-zoom
    Photo: iStockPhoto

    As police in Kansas City, Missouri, continue to look for missing 10-month old girl Lisa Irwin, detectives know where to begin their list of suspects: the toddler's parents.

    One reason? According to the National Center for Missing and Exploited Children, "the danger to children is greater from someone they or their family knows than from a stranger."

    And it happens all the time.

    NEWS: Artificial Intelligence Diagnoses Abuse

    According to figures released by UNICEF, over the past decade more than 20,000 American children are believed to have been killed in their own homes by family members. That is nearly four times the number of U.S. soldiers killed in Iraq and Afghanistan, and means that America has the worst record of child abuse in the industrialized world.

    Twenty-seven children under the age of 15 die from physical abuse or neglect every week in America. According to UNICEF, the United States has 2.4 annual deaths per 100,000 children, compared to 1.4 for France; 1 in Japan, and 0.9 in the United Kingdom.

    Why?

    According to Michael Petit, president of the advocacy group Every Child Matters, part of the reason for the striking disparity is that many risk factors associated with abuse and neglect (including teen pregnancy, violent crime, poverty and imprisonment) are generally much higher in America.

    Yet there may be hope: though these social problems are much higher in the United States than in other industrialized countries, most of these problems are actually getting better, not worse.

    For example according to a February 2010 "National Incidence Study of Child Abuse and Neglect" from the Department of Health and Human Services, "An estimated 553,000 children suffered physical, sexual or emotional abuse in 2005-06, down 26 percent from the estimated 743,200 abuse victims in 1993. The number of sexually abused children dropped 38 percent between 1993 and 2005. The number of children who experienced physical abuse fell by 15 percent and the number of emotionally abused children dropped by 27 percent."

    Furthermore, data from the Centers for Disease Control and Prevention's National Center for Health Statistics reported last year that the birth rate for U.S. teenagers fell 6 percent in 2009. The American teen birth rate fell to the lowest level ever recorded in nearly seven decades of tracking teenage childbearing.

    NEWS: Children Can Inherit Mom's Abuse-Altered Brain

    So by some measures the epidemic of child abuse should be getting better, not worse. However Petit also points out that there are other important factors contributing to the problem. For one thing, other countries with far lower abuse rates -- unlike the United States -- have social policies that provide child care, universal health insurance, pre-school, parental leave, and so on.

    All these social problems should not obscure one ugly fact: In the final analysis it is not lack of child care, or poverty, or teen pregnancy that is killing America's children. It is abusive mothers and fathers.

    According to a report titled "Homicide Trends in the U.S." issued by the Department of Justice's Bureau of Justice Statistics, of all children under age five murdered between 1976 and 2005, about two-thirds of them were killed by their parents: 31 percent were killed by fathers and 29 percent were killed by mothers.

    A 2003 study reported in the Journal of the American Medical Association found that at least 85 percent of North Carolina newborns who were killed or left to die were murdered by their mothers (usually through strangulation or drowning).

    Many studies suggest that mothers abuse and kill their infants and children at a higher rate than fathers. (This is probably due to the fact that women and mothers are more often the caregivers, so they have more overall contact with children -- both good and bad -- and are therefore overrepresented in child abuse cases.)

    According to Petit, as many as seven children die from abuse and neglect every day in America. If seven children were killed each day by strangers (or released sex offenders), the public would be outraged. Yet the public is largely unaware of (or indifferent to) parents who murder their children.

     


    UK:危うい NHS & Social Care 改革 [Social Policy]

    アメリカの民間医療保険依存のAffordable Health Care Actの命運は今や連邦最高裁にかかっていますが,イギリスでもNHS(国営医療)改革とSocial Care 改革がが危機に立たされています.

    イギリスでは国営医療制度(NHS)が戦後イギリス福祉国家の最大の成功例とされてきましたが,緊縮財政と共に,その順調な改良は停滞し,とりわけ政権交代(労働党政権から保守党・自由党連立政権に交代)を招いたイギリスの経済的低迷が,一方で財政削減を睨んだ「National Health Care & Social Care 改革」を,政治的Impass(袋小路)に追い込んでいます.

    それを象徴する出来事が,下記の,UK's largest medical college says the health and social care bill will 'damage patient care and jeopardise the NHS'として,政府改革提案をスクラップ化することを要求した提案に見ることが出来ます.

    いちいち詳細をご紹介はしませんが,イギリス最大のGeneral Practitioners の大学が,called for the prime minister to scrap the health and social care bill, branding it "damaging, unnecessary and expensive". という表現に,改革の困難さが象徴されています.

    "There is absolutely no evidence that opening up the NHS to multiple private organisations is going to result in anything other than a fragmented, expensive and bureaucratic health service for all of us, and one that will be very difficult to sort out and put back into a coherent form,"
    という意見に,問題の深刻さが窺われます.

    日本でもそうですが,医療,福祉の分野では既に強力なInterest Group ないし医療,福祉ビジネスが存在しますから,制度改革には相当な政治力が必要だというのは,世界的な共通事情といえます.

     

     

    Royal College of GPs calls for David Cameron to scrap health bill

    UK's largest medical college says the health and social care bill will 'damage patient care and jeopardise the NHS'

     

    Clare Gerada
    Dr Clare Gerada, head of the Royal College of GPs. Photograph: Frank Baron for the Guardian

    The UK's largest medical royal college has called for the prime minister to scrap the health and social care bill, branding it "damaging, unnecessary and expensive".

    The Royal College of General Practitioners (RCGP) has written to David Cameron following the tabling of amendments to the controversial bill in the House of Lords this week.

    They said that despite the amendments, they believed the planned reform would "cause irreparable damage to patient care and jeopardise the NHS".

    The RCGP chairwoman, Dr Clare Gerada, said: "This decision was not taken lightly, but it is clear that the college has been left with no alternative.

    "We have taken every opportunity to negotiate changes for the good of our patients and for the continued stability of the NHS, yet while the government has claimed that it has made widespread concessions, our view is that the amendments have created greater confusion.

    "We remain unconvinced that the bill will improve the care and services we provide to our patients."

    The college, which represents more than 44,000 family doctors, said three-quarters of respondents to a recent poll said they thought it appropriate to seek the withdrawal of the bill.

    It wrote to the health secretary, Andrew Lansley, to voice the concerns of their members but decided to take action after receiving his response, and following the government's tabling of amendments on Wednesday.

    Gerada said: "Our position has not changed, and the concerns we expressed when this bill was at the white paper stage 18 months ago have still not been satisfactorily addressed.

    "Competition and the opening up our of health service to any qualified providers will lead not only to fragmentation of care, but also potentially to a 'two-tier' system with access to care defined by a patient's ability to pay."

    The 20 colleges that make up the Academy of Medical Royal Colleges have been divided over the strength of the stance they should take against the bill.

    Those opposing it include the Royal College of Radiologists, which said it had "grave concerns", and the Royal College of Psychiatrists, which called the bill "fundamentally flawed".

    The British Medical Association, the Royal College of Nursing and the Royal College of Midwives have also called for the bill to be withdrawn.

    The government has been criticised for failing to allay fears over an increased role for private companies in running the NHS.

    A critical report from MPs on the health committee last month said the overhaul was hindering the ability of the NHS to make the savings it needs to safeguard its future.

    One of the amendments laid out this week said the NHS commissioning board and clinical commissioning groups run by GPs would have new responsibilities to support education and training. Both will also have to report annually on their progress in tackling health inequalities, together with the health secretary.

    Lansley said the government had been "carefully listening" to opinions about the bill and that the series of amendments would "address these remaining issues".

    Gerada added: "Our view is that what is required now is to rapidly consolidate the current organisational structure, such that PCT [primary care trust] clusters remain, with GPs placed as the majority of the board so that we may address the serious issues facing our NHS.

    "There should be a debate as a matter of urgency to determine what the NHS can provide, how it should be funded, and how we deal with the major health and social care problems facing our population.

    "We cannot sit back. Instead, we must once again raise our concerns in the hope that the prime minister will halt this damaging, unnecessary and expensive reorganisation, which, in our view, risks leaving the poorest and most vulnerable in society to bear the brunt."

    She said the college could not support a bill that would "ultimately bring about the demise of a unified national health service".

    Gerada told BBC Radio 4's Today programme: "This bill is a burden. It makes no sense, it is incoherent to anybody other than the lawyers. It won't deal with the big issues that we have to deal with, such as the ageing population and dementia.

    "It will result in a very expensive health service and it will also result in a health service that certainly will never match the health service that we have at the moment – or at least had 12 months ago."

    She rejected ministers' claims that GPs were enthusiastic about the reforms: "GPs do want to be part of the planning of services for their patients – absolutely, we have never ever been critical of that.

    "But that is one thing. Delivering it through this cumbersome bill is not what GPs want. Over 90% of my members surveyed last month wanted me to ask for withdrawal of the bill.

    "It will turn the National Health Service into thousands of different health services, all competing for the same patients, the same knee, the same brain, the same heart.

    "Patients will find their care will be fragmented, it will be on different sites, it won't join up, it will be difficult to hand over care and it will be phenomenally expensive to keep track of all these competing parts of the NHS."

    Gerada said the NHS was "one of the cheapest health services to run and one of the fairest health services" in the world.

    "There is absolutely no evidence that opening up the NHS to multiple private organisations is going to result in anything other than a fragmented, expensive and bureaucratic health service for all of us, and one that will be very difficult to sort out and put back into a coherent form," she said.

     


    Obama Health Care の命運:日本への示唆 [Social Policy]

    Obama Health Care の最近の動向をまとめておきます.

    下記の引用原文は,主な動きを伝えていますが,最近の重要な動きとして,アメリカのカソリック教会のBishop が女性の避妊,妊娠中絶に関わって,Obamaを宗教の自由を保障したアメリカ連邦憲法に違反すると厳しく批判したことが報じられています.
    Obamaは,2008年選挙では,カソリック教徒の過半数をかなり上回る得票に支持されていましたから,軽視できない問題です.

    下記の引用に見るように,保険の完全実施は2014年からですが,既に,連邦政府の事前準備が,一部の法律反対の州を除いて,徐々に進んでおり,医療界でも,中小病院が大規模病院に吸収される動きが強まっています.また,
    法律がすべてのアメリカ人に民間保険の購入を義務づけ,違反者からは罰金を取るという形ですから,保険会社で従来は既往症,特にガンなど死亡率の高い既往症歴のある者は「お断り」だったモノが,その拒否項目を外す動きが早まっています.それは,日本に進出しているアメリカ保険会社のTVコマーシャルを見ていても分かる通りです.

    日本の「税と社会保障の一体改革」という曖昧模糊とした政治宣伝にも影響を持つモノとしては,アメリカ政府が,せっかく難産の末に成立したHealth Care Act から,あっさりとLong-Term Care Insurance(ほぼ日本の介護保険に相当)を,財政的負担が大きく,かつ実際に機能させるのはきわめて困難だとして削除してしまったことがあげられます

    日本の介護保険も,来年度から,保険料が6,000円を超えるのではと報じられていますが,それは年金受給者にとっては天引きによる実質的年金給付水準引き下げというべきです.
    介護保険を巡っては,日本の介護保険料支払者は40歳以上ですから未だ徴収率が良い方ですが,本来の社会保険が危険を広く分担するモノという概念からすれば,当然,若年者からも徴収すべきモノです.
    それが,実態として,国民年金の保険料徴収率が60%を下回るほど低迷していますから,給与から天引きできるサラーリーマンに期待して40歳以上に押さえた経緯があり,政府が,今回,社会保障改革の内容を公表したがらない,ないしは,できない,ひとつの要因となっています

    私は,初めから,最も早く財政的困窮に陥った国民健康保険を救済するために考えられた,医療保険と別立の介護保険を制度化し社会保険制度をますます縦横に制度分割することに,一貫して反対してきており,その立場には変わりはありません.ですから,アメリカが昨年年10月になってLong-Term Care Insurance をカットしたのは適切な判断だったと考えます.

    ドイツの制度は,各州の負担である公的扶助から介護保険制度を分離独立させたモノでしたから,Medicare, Medicaid のあるアメリカや既に国民皆保険制度があり,生活保護から独立した老人福祉法も制度化していた日本にとって,さらに横割り縦割りに屋上屋を重ねる「介護保険制度」の必要性があったとはまったく考え難いのです.
     
    政府が年金制度を一元化するといい,序でに,最低保障年金を制度化するといっていることには,その内容が未だ不明で,私が主著「選別的普遍主義の可能性」で論じたモノにどれだけ近いかを計りがたいので,その点を見極めてから論じたいと考えていますが,せっかく年金制度の一元化を図るなら,介護保険を医療保険に一元化して,分立している医療保険制度も一元化すべきでしょう,

    もう一点,アメリカのAffordable Health Care Act についてですが,下記の記事以外に,アメリカ連邦最高裁の判事9人のうち2人について,この法律の違憲性の判断に触れるような発言を過去にした人として,自主的に判決に加わるべきでないという政治的プレッシャーが高まっていたのですが,最高裁長官が,連邦地裁や連邦高裁と違って,そうした適否を判断する上級裁判所がない最高裁の判事に対して,そうした政治的プレッシャーは認めがたいとして,拒否していましたから,3月下旬に3日間行われるヒアリング,そして6月というアメリカ大統領選挙に重大な影響を及ぼすであろう時期に行われる判決には,9人の判事の全員参加が予想されています.

    あとは,原文を,ご自由に,ご渉猟下さい.

     

     

     

    Regulatory Steps


    In the first 18 months after the law’s passage, some important provisions were put in place, including tougher oversight of health insurers, the expansion of coverage to one million young adults and more protections for workers with pre-existing conditions.

    More broadly, a combination of the law and economic pressures has forced major institutions to wrestle with the relentless rise in health care costs.

    From Colorado to Maryland, hospitals are scrambling to buy hospitals. Doctors are leaving small private practices. Large insurance companies are becoming more dominant as smaller ones disappear because they cannot stay competitive. States are simplifying decades of Medicaid rules and planning new ways for poor and rich alike to buy policies more easily.

    Even though critics say the law does little to reduce the costs of care, its passage touched off myriad efforts to pare widespread waste.

    And by November 2011, Federal officials had awarded nearly $516 million to states to help build new insurance exchanges, although some states whose officials are opposed to the law, like Florida and Alaska, have either refused the money or postponed any plans in hopes of getting the legislation overturned.

    Even without a significant expansion of Medicaid for the exchanges, state programs will soon be transformed through a provision that tries to standardize some of the byzantine eligibility and other rules. It requires states to offer a single, simple Internet application for not only Medicaid recipients but everyone seeking care on health exchanges.

    But an inspector general’s report from the Treasury Department indicated that fewer small businesses than expected had taken advantage of a tax credit under the law that encourages providing coverage for employees.

    Republican Attempts to Repeal

    In the November 2010 elections, Republicans took back control of the House and cut the Democratic majority in the Senate. After a delay caused by the shooting of Representative Gabrielle Giffords in Tucson, Ariz., the House voted on January 19, 2011 to repeal the health care overhaul, marking what the new Republican majority in the chamber hailed as the fulfillment of a campaign promise and the start of an all-out effort to dismantle President Obama’s signature domestic policy achievement.

    The House vote was the first stage of a Republican plan to use the party’s momentum coming out of the midterm elections to keep the White House on the defensive, and will be followed by a push to scale back federal spending. In response, the administration struck a more aggressive posture than it had during the campaign to sell the health care law to the public. With many House Democrats from swing districts having lost their seats in November, the remaining Democrats held overwhelmingly together in opposition to the repeal.

    Knowing that a full-scale repeal would be blocked by the Senate and Mr. Obama, Republicans say they will try to withhold money that federal officials need to administer and enforce the law.

    Republicans also intend to go after specific provisions, including requirements that many employers to offer insurance to employees or pay a tax penalty and that most Americans obtain health insurance. Alternatively, Republicans say, they will try to prevent aggressive enforcement of the requirements by limiting money available to the Internal Revenue Service, which would collect the tax penalties.

    The repeal effort is part of a multipronged systematic strategy that House Republican leaders say will include trying to cut off money for the law, summoning Obama administration officials to testify at investigative hearings and encouraging state officials to attack the law in court as unconstitutional. For House Republicans, a repeal vote would also be an important, if largely symbolic, opening salvo against the president, his party and his policy agenda.

    Republicans denounced the law as an intrusion by the government that would prompt employers to eliminate jobs, create an unsustainable entitlement program, saddle states and the federal government with unmanageable costs, and interfere with the doctor-patient relationship. Republicans also said the law would exacerbate the steep rise in the cost of medical services.

    For their part, the Obama administration and Democrats, who largely lost the health care message war in the raucous legislative process, see the renewed debate as a chance to show that the law will be a boon to millions of Americans and hope to turn “Obamacare” from a pejorative into a tag for one of the president’s proudest achievements. Democrats argue that repeal would increase the number of uninsured; put insurers back in control of health insurance, allowing them to increase premiums at will; and lead to explosive growth in the federal budget deficit.

    Republicans said their package would probably include proposals to allow sales of health insurance across state lines; to help small businesses band together and buy insurance; to limit damages in medical malpractice suits; and to promote the use of health savings accounts, in combination with high-deductible insurance policies.

    Republicans also want to help states expand insurance pools for people with serious illnesses. The new law includes such pools, as an interim step until broader insurance coverage provisions take effect in 2014, but enrollment has fallen short of expectations. They have also proposed allowing people to buy insurance across state lines and to join together in “association health plans,” sponsored by trade and professional groups.

    But state insurance officials have resisted such proposals, on the ground that they would weaken state authority to regulate insurance and to enforce consumer protections — a concern shared by Congressional Democrats.

    Mr. Obama has responded to criticism by saying he would be willing to amend portions of the law. On Feb. 28, 2011, he endorsed bipartisan legislation that would allow states to opt out earlier from a range of requirements, including the mandate, if they could demonstrate that other methods would allow them to cover as many people, with insurance that is as comprehensive and affordable, as provided by the new law. The changes must also not increase the federal deficit.

    If states can meet those standards, they can ask to circumvent minimum benefit levels, structural requirements for insurance exchanges and the mandates that most individuals obtain coverage and that employers provide it. Washington would then help finance a state’s individualized health care system with federal money that would otherwise be spent there on insurance subsidies and tax credits.

    Prospects for the proposal appear dim. Congress would have to approve the change through legislation, and House Republican leaders said that they were committed to repealing the law, not amending it. Even if the change were approved, it could be difficult for states to meet the federal requirements for the waivers.

    Scrapping Long-Term Care Coverage

    In October 2011, the Obama administration announced that it was scrapping a long-term care insurance program created by the new law because it was too costly and would not work.

    The program, known as Community Living Assistance Services and Supports, or Class, was intended for people with chronic illnesses or severe disabilities who wanted to live in the community, though benefits could also have been used to help pay for nursing home care or assisted living.The program would have been financed with premiums paid by workers, through voluntary payroll deductions, with no federal subsidy. Premiums were supposed to have ensured the solvency of the program over 75 years.

    But Kathleen Sibelius, secretary of health and human services, said she had concluded that premiums for the program would be so high that few healthy people would sign up.

    She said she agreed with actuaries who feared that “not enough young, healthy people” would enroll. “This could have led to a vicious cycle where premiums would have to be set higher and higher to cover the likely costs of benefits, leading fewer and fewer healthier people to sign up for the program,” she said.

    Court Challenges

    Immediately after Mr. Obama signed the bill, states began filing challenges to it in federal court. Twenty states, led by Attorney General Bill McCollum of Florida, a Republican who is running for governor, banded together to file suit in federal district court in Pensacola, Fla. The first challenge to make it to a hearing was the one filed by the attorney general of Virginia.

    In October, a federal judge in Detroit became the first to rule on the lawsuits, upholding the government’s position. The next month, a federal judge in Lynchburg, Va., did the same.

    Then in December, a federal judge in Richmond issued the first ruling against the law, calling the individual mandate unconstitutional. The judge, Henry E. Hudson, who was appointed by President George W. Bush, wrote that his survey of case law “yielded no reported decisions from any federal appellate courts extending the Commerce Clause or General Welfare Clause to encompass regulation of a person’s decision not to purchase a product, not withstanding its effect on interstate commerce or role in a global regulatory scheme.”

    The case centered on whether Congress has authority under the Commerce Clause to compel citizens to buy a commercial product — namely health insurance — in the name of regulating an interstate economic market. Plaintiffs in the lawsuits argue there effectively would be no limits on federal power, and that the government could force people to buy American cars or, as Judge Hudson remarked at one hearing, “to eat asparagus.”

    The Supreme Court’s position on the Commerce Clause has evolved through four signature cases over the last 68 years, with three decided since 1995. Two of the opinions established broad powers to regulate even personal commercial decisions that may influence a broader economic scheme. But other cases have limited regulation to “activities that have a substantial effect on interstate commerce.”

    A major question, therefore, has been whether the income tax penalties levied against those who do not obtain health insurance are designed to regulate “activity” or, as Virginia’s solicitor general, E. Duncan Getchell Jr., has argued, “inactivity” that is beyond Congress’ reach.

    Justice Department lawyers responded that individuals cannot opt out of the medical market, and that the act of not obtaining insurance is an active decision to pay for health care out of pocket. They say that such decisions, taken in the aggregate, shift billions of dollars in uncompensated care costs to governments, hospitals and the privately insured.

    In January 2011, Judge Roger Vinson of Federal District Court in Pensalcola, Fla., became the second to rule against the health care law. His ruling came in the most prominent of the more than 20 legal challenges mounted against some aspect of the sweeping health law.

    Only Judge Vinson has declared the entire act void, including provisions that have already taken effect, like requirements that insurers cover children regardless of pre-existing conditions. Three other federal judges, meanwhile, have upheld the law.

    In June 2011, a two-judge panel of the appeals court for the Sixth Circuit upheld the law, in what was the first of three appellate decisions.

    As they look ahead to the Supreme Court, the law’s defenders can take encouragement from the concurring opinion written by Judge Jeffrey S. Sutton, an appointee of President George W. Bush, a Republican. Judge Sutton is typically considered conservative on questions of constitutional reach.

    After acknowledging the difficulty of pinpointing the limits on Congress’s power to regulate interstate commerce, Judge Sutton wrote, “In my opinion, the government has the better of the arguments.” He added, “Not every intrusive law is an unconstitutionally intrusive law.”

    Concerning the mandate, Judge Sutton added, “Inaction is action, sometimes for better, sometimes for worse, when it comes to financial risk.” Whether an individual buys an insurance policy or not, the judge wrote, “each requires affirmative choices; one is no less active than the other; and both affect commerce.”

    In August 2011, a divided three-judge panel of the 11th Circuit Court of Appeals struck down the so-called individual mandate, which is considered the centerpiece of the law, ruling that Congress exceeded its powers to regulate commerce when it decided to require people to buy health insurance. But the court held that while that provision was unconstitutional, the rest of the wide-ranging law could stand.

    In September 2011, a federal appellate court in Richmond, Va., threw out a pair of cases challenging the constitutionality of the Affordable Care Act, ruling for varying reasons that the plaintiffs did not have legal standing to sue. In the process, two of the three judges on the panel volunteered that they would have upheld the law if they had been able to rule on the substance of the cases.

    The Supreme Court Steps In

    On Sept. 28, the Justice Department asked the Supreme Court to review the decision from the 11th Circuit invalidating the mandate.

    On Nov. 14, the court agreed to hear a challenge to the law. The development set the stage for oral arguments by March and a decision in late June, in the midst of the 2012 presidential campaign. The development set the stage for oral arguments by March and a decision in late June, in the midst of the 2012 presidential campaign.

    The court’s decision to step in had been expected, but the order answered many questions about just how the case would proceed. The court scheduled five and half hours of argument instead of the usual one, a testament to the importance of the case, which has as its center an epic clash between the federal government and the 26 states that together filed a challenge to the law.

    The justices will hear two hours of argument on whether Congress overstepped its constitutional authority, 90 minutes on whether the mandate may be severed from the balance of the law if Congress did go too far, and an hour each on the Medicaid and Anti-Injunction Act questions.

    The court will hear three appeals, two from challengers to the law and a third from the Obama administration. The appeals involving the 26 states is Florida v. Department of Health and Human Services, No. 11-400. A second challenge, from a business group and two individuals, is National Federation of Independent Business v. Sebelius, No. 11-393.

    The federal government’s appeal is Department of Health and Human Services v. Florida, No. 11-398.