This article examines the consequences of the decentralization process that is under way in Costa Rica and which may undermine, rather than bolster, democracy in that country. I first outline three key contextual variables relating to the reform process: existing sociopolitical realities (constructing local legitimacy), the dynamics of the reform process (bottom-up versus top-down), and the timing or sequencing of the proposed reforms (what is being decentralized and when). Though I focus here on Costa Rica, these three variables are generally applicable in any case of decentralization. After considering these contextual factors, I evaluate the likelihood of four negative side effects arising from the ongoing decentralization process: party-system fragmentation, reinforced or mutated clientelism, intermunicipal conflict and polarization, and local government instability. Early evidence suggests that some of these effects, particularly party-system fragmentation and municipal instability, have begun to manifest themselves.

Among internists providing primary care at 4 VA medical centers, there were no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification on 10 primary care performance measures. Additional research to examine the difference in patient outcomes among holders of time-limited and time-unlimited certificates in non-VA and nonacademic settings and the association with other ABIM goals may help clarify the potential benefit of Maintenance of Certification participation.

While low literacy was not predictive of admission preventability, the formal assessment of alcohol binge drinking, social support for medical care, social network size, and prior outpatient utilization may enhance our ability to predict the preventability of hospitalizations and develop targeted interventions.

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