Refereed publications

2021. Isabel M. Perera. "Interest Group Governance and Policy Agendas," in Governance [PDF]

  • APSA Health Politics Section Leonard S. Robins Best Paper Award, 2018

  • LSE International Health Policy Conference Best PhD Paper Award, 2017

This article proposes that the internal political organization of an interest group can shape its policy agenda. In doing so, it recommends that public policy research draw on scholarship on comparative political institutions to identify and theorize how alternative organizational rules, structures, and mechanisms can shape preference formation and expression. For example, confederal interest groups can amplify minority voices, whereas majoritarian groups can silence them. Contrasting cases of physician advocacy in mental health policy illustrate how the confederal approach to medical organization in France expanded the influence of a small group of public sector psychiatrists; while the majoritarian, “winner-take-all” approach to medical organization in the United States sidelined their American counterparts in favor of the private sector majority. These findings suggest that the politics of interest-aggregation merit further investigation.

2021. Julia F. Lynch, Isabel M. Perera, and Theodore J. Iwashyna. "Scarce Resource Allocation in a Pandemic: A Protocol to Promote Equity, Timeliness, and Transparency" in Critical Care Explorations

Shortages of equipment, medication, and staff under coronavirus disease 2019 may force hospitals to make wrenching decisions. Although bioethical guidance is available, published procedures for decision-making processes to resolve the time-sensitive conflicts are rare. Failure to establish decision-making procedures before scarcities arise exposes clinicians to moral distress and potential legal liability, entrenches existing systemic biases, and leaves hospitals without processes to guarantee transparency and consistency in the application of ethical guidelines. Formal institutional processes can reduce the panic, inequity, and irresolution that arise from confronting ethical conflicts under duress. Drawing on expertise in critical care medicine, bioethics, and political science, we propose a decision-making protocol to ensure fairness in the resolution of conflict, timely decision-making, and accountability to improve system response.

2021. Bailey Rose-Marie Fairbanks, Fabian Neuner, Isabel M. Perera, and Christine M. Slaughter. “Pay to Play? How Reducing APSA Division Fees Increases Graduate Student Participation," in PS: Political Science & Politics. [PDF]

In 2017, the American Political Science Association (APSA) Committee on the Status of Graduate Students in the Profession launched an initiative to lower the cost of Division (i.e., organized section) membership for students to promote graduate students’ professional development and to advance Division interests. This article assesses the effect of this intervention on Division membership. Using APSA membership data, we find that almost two thirds of Divisions that charged fees in 2017 reduced or eliminated student fees between 2017 and 2019, nearly halving the average student dues (i.e., from $11.57 in 2017 to $5.84 in 2019). As a result, average student membership increased by more than 300% in Divisions that reduced fees (i.e., from 79.5 in 2017 to 248.7 in 2019), compared to a marginal 30% increase in those that did not reduce fees. These outcomes of the initiative support additional efforts to reduce the costs of APSA participation for graduate students.

2021. Isabel M. Perera and Alex V. Barnard, "Myths of Mental Health: Revelations from a French-American Comparison," in Perspectives in Medicine and Biology [PDF]

Drawing on an analysis of the French mental health system, this essay examines four presumptions about mental health care dominant in the United States. Claims about 1) the required abolition of the hospital for psychiatric deinstitutionalization, 2) the substitutability of public and private financing, 3) the importance of a “dangerousness” criterion for involuntary commitment procedures, and 4) the need for an ever-expanding scope of care hold little weight when subjected to comparative scrutiny. We close by discussing the implications of these revelations for U.S. mental health care policy and ethics.

2021. Isabel M. Perera, "What Doctors Want: A Comment on the Financial Preferences of Organized Medicine," in the Journal of Health Policy, Politics, and Law [PDF]

Organized medicine’s persistent demand for high payments is one factor that contributes to the rising costs of health care. The profession’s longstanding preference for private and fee-for-service practice has pressured payers to increase reimbursement rates in fee-based systems; and it has stalled, thwarted, or otherwise co-opted attempts to contain costs in other payment systems. Yet what doctors want in fact varies. This comment revisits classic comparative studies of organized medicine in the advanced democracies to highlight two under-emphasized findings: (1) physicians’ financial preferences can deviate from traditional expectations, and (2) the structure of the organizations that represent doctors can shape whether and how those preferences are expressed. These findings remain relevant today, as a discussion of contemporary American health politics illustrates.

2020. Stephen Allison, Tarun Bastiampillai, Jeffrey C.L. Looi, Simon Judkins, and Isabel M. Perera. "Emergency department–focused mental health policies for people with severe mental illness," in the Australian and New Zealand Journal of Psychiatry

The logic of French mental health policy—which already stands out against that of other countries—also appears at odds with the usual logic of French social policy. "La sectorisation psychiatrique” rejected the liberalism prominent in the rest of the health system, adopted Beveridgean principles decades in advance of other policy areas, and began to centralize precisely during the period of déconcentration. This article explains these puzzles by pointing to the role of public sector trade unions. Archival sources document how the historical advocacy of unions representing public psychiatric workers shaped public policy in mental health. Examining their political activity can revise standard interpretations of the French welfare state and illuminate a generalizable theoretical relationship for comparative analysis.

2020. Isabel M. Perera and Desmond King, “Racial Pay Parity in the Public Sector: The Overlooked Role of Employee Mobilization” in Politics & Society [PDF]

Rising economic inequality has aggravated long-standing labor market disparities, with one exception: government employment. This article considers the puzzle of black-white wage parity in the American public sector. African Americans are more likely to work in the public than in the private sector, and their wages are higher there. The article builds on prior work emphasizing institutional factors conditioning this outcome to argue that employee mobilization can motor it. As public sector unions gained political influence postwar, their large constituencies of black, blue-collar workers, drawing on both militant and nonviolent tactics of the urbanizing civil rights movement, advocated for improved working conditions. Archival sources confirm this pattern at the federal level. The employment and activism of African Americans in low-skilled federal jobs pivoted union attention to blue-collar issues and directly contributed to the enactment of a transparent, universal wage schedule for the blue-collar federal workforce (the Federal Wage System). The result was greater pay parity for African Americans, as well as for other disadvantaged groups.

2020. Isabel M. Perera,The Relationship between Hospital and Community Psychiatry: Complements, Not Substitutes?” in Psychiatric Services

Community-based psychiatric services are essential to mental health. For decades, researchers, advocates, and policy makers have presumed that expanding the supply of these services hinges on reducing the supply of hospital-based care. Cross-national data from the World Health Organization call this presumption into question. Community and hospital psychiatry appear to be complements, not substitutes.

2019. Isabel M. Perera, “Mental health and politics since the eurozone crisis,” in European Psychiatry [PDF]

Some of the most immediate health effects of the 2008 economic crisis concerned the mind, not the body. Rates of generalized anxiety, chronic depression, and even suicide spiked in many European societies. This viewpoint highlights the role of mental health professionals in responding to this emergency, and argues that their sustained mobilization is necessary to its long-term resolution.

2019. Isabel M. Perera and Dominic A. Sisti, “Mass Shootings and Psychiatric Deinstitutionalization, Here and Abroad,” in the American Journal of Public Health [PDF]

Is deinstitutionalization to blame for the regularity of mass shootings in America? Deinstitutionalization occurred not only here but also across other high-income democracies. Major international organizations, such as the World Health Organization, have supported the reduction of hospital psychiatry. Comparing cross-national data of mass shootings—typically defined as four or more fatalities—with the decline of inpatient psychiatric capacity offers little evidence to support this association.

2019. Isabel M. Perera,Is Psychiatry Different? An Economic Perspective,” in the Lancet Psychiatry [PDF]

Compared with the general health system, the mental health system faces distinct challenges. Perennial flashpoints include issues of stigma, coercive treatment, and nosology, which generate heated ethical and policy debates. Often overlooked, however, is another characteristic of the mental health sector: its financial dependence on the public purse.

2017. Julia F. Lynch and Isabel M. Perera,Framing Health Equity: U.S. health disparities policy in comparative perspective,” in the Journal of Health Policy, Politics, and Law [PDF]

In this article we explore systematically the different conceptions of health equity in key national health policy documents in the United States, the United Kingdom, and France. We find substantial differences across the three countries in the characterization of group differences (by SES, race/ethnicity, or territory), and the theorized causes of health inequalities (socioeconomic structures versus health care system features). In all three countries, reports throughout the period alluded at least minimally to inequalities in social determinants as the underlying cause of health inequalities. However, even in the reports with the strongest attachment to this causal model, the authors stop well short of advocating the redistribution of power and resources that would likely be necessary to redress these inequalities.