Health Politics: Lecture 10 Summary

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Health PoliticsLecture 10Summary

• Ana Rico, Associate Professor
• Department of Health Management and Health
  Economics
• ana.rico_at_medisin.uio.no

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THE DEPENDENT VARIABLESTypes of WS and HC
systems- Policy instruments- Impact Social
outcomes
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1. THE WS, POLITICS MARKETS Definition
GOVERNANCE POLITICS
DEMOCRATIC GOVERNMENT INSTITUTIONS
INTEREST GROUPS
THE MARKET
Financial markets
PUBLIC SOCIAL INSURANCE
THE WS
PRIVATE FINANCERS Banks, insurers, citizens
Product markets
PUBLIC WELFARE SERVICE PRODUCTION
PRIVATE PROVIDERS Hospitals, doctors, schools,
nursing homes
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2 3. TYPES OF WS Instruments and consequences
UNIVERSAL
Pure (unmixted) Socialdemocratic
Pure Christian Democratic Employees
EGALITARIAN Outcomes REGRESSIVE
- Covered
Pure liberal Private insurance for the non-poor
Pure liberal Public insurance for the poor
Pure ChisDem Non-employed
Pure CD Private insurance for employers
RESIDUAL
Based on Esping-Andersen, 1990
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Source McKee, 2003
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CHANGES IN WELFARE POLICY

• WS expansion
• Expansion of coverage, benefits and expenditure
• WS retrenchment
• Decrease in coverage, benefits and expenditure
• WS resilience
• Stable in coverage, benefits and expenditure.
  Resistant to change
• WS re-structuring
• Change in distribution of benefits expenditure
  across social groups

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HC in CRISIS Canada US
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HC IN CRISIS? Canada, gov. approval
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THE INDEPENDENT VARIABLES- The political
sysem- Context, actors, instits. , action
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Political, policy/sociopolitical and social
systems
SOCIAL CONTEXT
CULTURE
POLICY (SUB-) SYSTEM

• Social organiz.
• Associations
• Churches
• Firms

THE POLITICAL SYSTEM
Ideologies Ideas

• Sociopol. actors
• IGs, Prof Ass., Unions
• Citizens, Mass media
• Political parties

Policy change
a
c

• Policy actors
• STATE-, POL. PARTs (IGs)

Org.Struct.
Subcultures /pol.identities
b
HC SYSTEM
CONSTITUTION

• Interactions
• Coalitions/competit.
• Leadership/strategy

Social groups - Communities - Ethnia,
gender - Social classes

• Institutions
• Const. (interorg.)
• Organiz. Struct.

Outputs
e
d
f
Outcomes
OUTPUTS
INPUTS

• Demands and supports
• Access to the political system
• Decision-making

d. Institutional change e. Impact of policy f.
Distribution of costs and benefits
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Policy
MACRO Political actors
The political game
MESO Sociopol. actors

HC SYSTEM
Advisors and managers
Political parties members
Citizens Associations
IGs - Bussiness - Insurance
Profes. providers Assoc.
Patients Assoc.
Patients
The socio-political context
MICROSocial actors
The social context
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ACTION-CENTERED THEORIES. 1.1. RQs
REPRESENTATIVE DEMOCRACY
DIRECT DEMOCRACY
RQ 2. Who influences policy?
RQ 3. Who governs?
RQ 4. How it governs?
RQ 1. Who participates? ( seeks to influence
policy)
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THE THEORIES- Concepts- Hypotheses- Causal
maps
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CONCEPTS (4) The state

• SOCIAL CONTEXT The state as a transmission
  belt of social pressures
• STATE-CENTRIC The state as a unitary,
  independent actor with formal monopoly of
  (residual) power over policy-making
• STATE-SOCIETY The state as a set of political
  representatives and policy experts with
  preferences and action partly independent, and
  partly determined by a wide range of social
  actors pressures
• INSTITUTIONALIST The state as a set of political
  institutions or as a set of elites with
  preferences and actions mainly determined by
  institutions
• ACTION As a set of political organizations which
  respond to context, sociopolitical actors and
  institutions and which compete and cooperate
  (interact) to make policy

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SOCIAL POLITICAL THEORIES
L7
L3
1950s/60s SOCIAL CONTEXT
OLD INSTITUTIONALISM Formal political institutions
SOCIAL PRESSURES
L2, L4
SOCIAL ACTORS (IGs dependent on social pressures)
L5
POLITICAL ACTORS (STATE independent of social
pressures)
1970s/1980s ACTOR-CENTRED
L6
SOCIOP. ACTORS (STATE-SOCIETY interdependent)
1990s INSTITUT-IONALISM (state-society)
L7
NEW INSTITUTIONALISM (state institutions
state/PPs/IGs organization)
L9
L4, L9
L7, L9
POWER-CENTRED THEORIES (interactions among
collective actors social structure)
2000s ACTION THEORIES
RATIONAL CHOICE (interactions among individuals
ACTOR-CENTERED INSTITUTIONALISM (interactions
among institutions elites)
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CAUSAL MAPS
Social context social actors theories
Proposals of politically active groups
Changing class structure new social needs
Socioeconomic cultural changes
Government action/Policy change
State-centered theories
How state organizations parties operate
Government action/Policy change
State formation (bureaucratization,
democratization
Changing group and social needs
What politically active groups propose
Source Orloff Skocpol, 1984
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CAUSES OF THE WS
Christian conservative parties, insurers,
unions voters
Coalition formation Political competition
Electoral campaigns Policy campaigns
Dominant national subcultures
Socialdemocratic parties, unions voters
Social structure
Policy change
Liberal parties, progressive (state) elites,
social protest
SOCIAL
POLITICAL
POLICY
SOCIOPOL.
Based on Esping-Andersen 2000 2003 Jenkings
Brents 1987 Skocpol 1987
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THE THEORIES (2)- Old and new debates
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SOCIAL vs. POLITICAL THEORIES
FATE
POLITICAL ACTORS (as representatives) ?
independent of social groups

• SOCIAL CONTEXT
• Convergence theory
• Structural theories capitalist/working class
  strength depends on distribution of ownership
• Cultural theories national (anti- or statist)
  cultures inherited from history
• Contextual theories unusual conjunctures, policy
  windows

INTERESTGROUPS (as delegates of social groups ?
dependent on mandate)
CHOICE
SOCIOPOLIT. ACTORS ? interindependent

• Bussiness associations Unions
• Professional associations
• Policy experts
• Citizens preferences ( PO)
• Mass media
• Social movements

CHANCE
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ACTORS ACTION ACROSS THEORIES
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ACTION-CENTERED THEORIES

• Positions in the main debate on causation in
  policy sciences
• From actor-centered (simple) to action-centered
  (complex)
• From monocausal explanations emphasys on one
  actor as key determinant
• To multicausal models which
• Compare the relative preferences power
  resources of actors
• Analize the interactions between institutions,
  past policy and context
• Map actors changing choices and strategies
• Examine actors interactions in the political
  process...

Interaction models
Rational models
Incremental models
Institutionalism
Rational choice
Power-centred theories

• Individuals
• Interests
• Resources
• Competition

• Social groups
• Power resources
• Collective action
• Coalitions

• Organizations
• Rules norms
• Expectations
• Formal power

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TOWARDS TWO MAIN THEORIES?

• POWER-CENTRED TEORIES
• ? FROM (EC.) ACTION THEORIES
• Changing strategy resources as key causes of
  policy change
• Actors as complex coalitions of political
  organizations and social groups steered by
  political leaders enterpreneurs
• ? FROM STRUCTURAL THEORIES
• Social power resources as the main actors
  characteristic
• Politics as an unequal, oligopolistic game in
  which stakeholders have permanent advantage
• Access and strength of stakechallengers weakest
  social groups explains policy change
• Stakeholders must be divided

• ACTOR-CENTRED INSTITUTIONALISM
• FROM (EC.) ACTION THEORIES
• Choice strategy as key causes of policy change
• Political actors as individuals ? links with
  society reduced to basic resources (, vote)
  internal cohession assumed rather than
  investigated
• Preferences as the main actors feature formal
  institutional power resources
• Politics as a balanced game interests compete on
  equal terms, none has permanent advantage
• FROM ACTOR-CENTRED THEORIES
• Dominant actors (with formal, institutional
  political power) explain policy change

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CAUSES OF POLICY CHANGE Operationalization in
WS/HC research

• Access participation
• Policy strategies
• Coalition-building
• Competition and cooperat.
• Changing resources
• Learning

• Conjunctural factors ec crisis, wars

• Socioeconomic structure
• Ownership, income
• Education, knowledge
• Social capital (status, support)

CONTEXT

• Sociopolitical structure
• Cleavages and political identities

• Values Culture and subcultures

• Interest groups
• Profesional assocs.
• Poilitical parties
• State authorities
• Citizens PO/SM
• Mass media

• Distrib. of formal pol. power electoral law,
  constitution, federalism, corporatism
• Contracts and org. structures
• Norms of behaviour
• Sanctions/incentives

POLITICS Strategies, Interactions
Preferences Resources
INSTITUTIONS
POLITICAL ACTORS
Individual and collective
-
Formal and informal

• Entitlements rights
• Regulation of power, ownership, behaviour,
  contracts)
• Redistribution Financing RA
• Production of goods services

POLICY
Adapted from Walt and Wilson 1994
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EVIDENCE DETERMINANTS OF WS EXPANSION
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EVIDENCE

• Actor-centred institutionalist theory HUBER et
  al 1993 (cont.)
• First incorporation of political institutions
  (constitutional structure)
• Strength of federalism low, medium, high
• Strength of bicameralism low, medium, high
• Existence of presidentialism yes, no
• Electoral system Majoritarian, proportional
  modified, proportional
• Popular referendum yes, no
• Left corporatism degree
• (Openess of voting regulation estimated via
  voter turnout)
• First disaggregation of the DV The outcome we
  should study is not pro-WS or anti-WS but but
  rather the type of welfare policies eg.
• Expenditure in Social Security benefits (total)
• Expenditure in transfer payments (cash transfers
  excludes health care)
• Government revenue (indicator of state capacity ?
  state ownership)
• Entitlements who are the beneficiaries, on which
  basis (income, employment, citizenship) ?
  Decommodification index (L1)
• Benefits equality (vs. Benefits proportional) ?
  REDISTRIBUTION

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EVIDENCE
Actor-centred institutionalist theory HUBER et
al 1993 (cont.)

• 1. Socioeconomic context (as control variables)
• Aged, unemployed, economic growth, price
  profits level
• 2. Actors (1) Partisanship theory
• Socialdemocratic government boost expenditure,
  universalism public provision of services
  weak effects on cash transfers
• Christian Democratic parties boost cash transfers
  proportional to income
• 3. Actors (2) Statist theory
• Strong effects of state fiscal capacity
• Weaker effects of state employment capacity
• 4. Institutions Statist/institutionalist theory
• Inconsistent effects of government centralization
  and corporatism
• Significant effects of constitutional structure
  (number of veto points)
• 5. Process and action
• Strong effects of political mobilization
  (voting) of the lower classes
• But not of social protest

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EVIDENCE

• General findings on causal mechanisms behind WS
  expansion
• A. Some factors have direct, clear effects
• Strength of Social Christian Democracy (strong
  subcultures parties)
• Constitutional structure (institutional
  concentration of state power)
• State fiscal capacity (financial power resources
  of the state)
• B. Other factors have less direct effects, either
  contingent (on conjuncture/country) and/or
  conditional (on interactions with other vars.)
• Eg. Federalism, social protest, economic
  context, state employment capacity
• C.Other factors are so correlated to each other
  that is difficult to know about their independent
  effects on policy
• Eg. Aging and left vote consensual democracy
  and corporatism

Actor-centred institutionalist theory HUBER et
al 1993 (cont.)
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ACTION-C. THEORIES. 4. Evidence

• 1. Interactions among IVs ? or need to split into
  two (recodification)
• 1. Social protest ( social groups)
• Mobilization of lower classes WS
• Mobilization of upper classes - WS
• Mobilization aparently no signficant effects on
  WS
• Need to model the interaction No. Mobilized
  Predominant upper (0) / lower (1) classes
• Or split the varible No. mobilized lower
  classes/Idem upper
• 2. Correlations between Ivs (multicollineality)
  need to ommitt some
• 1. Ec. development, old age and left vote
• Direct or indirect effects of aging?
• 2. Openess of the economy, left ChD vote,
  corporatism, WS expenditure

Aging
WS expansion
Left vote
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ACTION-CENTRED THEORIES. 4. Evidence
A. Power-centred theory Hichs Mishra (cont.)
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THE FUTURE THE BATTLE FOR PUBLIC OPINION IN
HEALTH POLITICS
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WHY IS RELEVANT? (1)

• Public opinion citizenss preferences and
  perceptions
• 1. AS AN INPUT in health care (HC) reform
• Citizens as voters (voice), users (exit) and
  tax-payers (loyalty) in democracies
• Main input in politicians utility functions
• An independent determinant of policy?
• The debate on manipulation Schumpeter vs. Jacobs
• A critical determinant of policy when...
• Well-established, non-ambivalent attitudes
  resulting from active interpretation discussion
  (political mobilization and civic culture)
• Democratic competition divergent elites
  messages
• Very popular or impopular policies (issue
  salience)

Schumpeter JA (1950) Capitalism, Socialism and
Democracy, NY Harper. Jacobs
(2001) Manipulators and manipulation Public
opinion in a representative democracy, Journal of
Health Politics, Policy and Law, 26, 6, 1361-1373.
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WHY IS RELEVANT? (2)

• In health care
• critical for electoral success democratic
  legitimacy
• intense preferences but high asymmetric
  information
• In health care reform
• Jacobs 1992 undivided and unambiguous PO
  reinforces state autonomy as it counterbalances
  IG pressures (UK 1945 vs US 1965)
• Navarro 1989/Quadagno 2004 powerful IGs in the
  USA (AMA 1920s-1960s Insurers 1980s-2000s both)
  invest substantial resources in counter-reform PO
  campaigns (Immergut 1992 on Switzerland)
• Jacobs 2003 Harry Louise against the Clintons
  unmanipulated PO requires competitive mass media
  political mobilization (soc. mov.)
• Briggs 2000 (/Hall 1993/Weir Skocpol 1984)
  Social scientists, unions and policy
  enterpreneurs played a critical role in
  counterbalancing IGs campaigns in Europe

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WHY IS RELEVANT? (3)

• 2. As a PROXY of PROCESS
• Access, Pathways, Management
• Information, Trust, Shared decision-making
• 3. AS AN OUTCOME of HC (reform)
• Equity, financing and distributive justice
• Satisfaction, quality of life and productive
  efficiency
• NOTE
• Citizens disatisfaction, AND perceptions of
  process equity problems are indicators of bad
  performance of public HC
• Perceived performance constitutes the most
  important causeinput of HC reform for
  policy-feedback theory

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DETERMINANTS

• Interests social structure vs. choice
• Values ? CULTURE
• As core beliefs solidarity, equality, safety
• Varying by ideological subcultures
• Social-democracy universality, solidarity
• Political liberalim equality of opportunity
• Progressive conservatism responsibility, safety
  
• Peers, Media, Elites (politicians, doctors,
  industry) ? POLITICS
• Performance ? POLICY
• experienced and perceived
• egocentric and sociotropic

Based on Maioni A (2002) Is public health care
politically sustainable?, Presentation for the
Canadian Fundation for Humanities and Social
Sciences and
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RECENT TRENDS

• Its role is expanding...
• In health policy ideas, evidence, leadership
• In health politics conflict over resouces,
  deciding on rules and responsibilities, battle
  for public opinion
• ... Due to increased salience more informed
  citizens
• (Maioni, 2002 reference in previous slide)
• Its shape is changing...
• Increased perception of crisis (finance, access,
  quality)
• Satisfaction with medical care received high
• Stable or expanding core values HC as a social
  right
• Media and industry more influential doctors
  peers less government depends
• More educated autonomous citizens?

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DETERMINANTS OF SUPPORT FOR STATE INVOLVEMENT,
24 OECD countries, ISSP 1997
Source Blekesaune M and Quadagno J (2003)
Public attitudes towards welfare state policies
A comparative analysis of 24 nations, European
Sociological Review, 19, 5 415-427.
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PO SUMMARY CONCLUSIONS

• Public opinion (citizens preferences and
  perceptions)
• Plays a critical role in democracy
  responsiveness, accountability, quality of
  democracy
• Is also useful as a HC input outcome to track
  process
• Sits at the centre of politicians utility
  functions, and is a critical determinant of
  public policy (veto)
• Is increasingly the target of IGs public opinion
  campaigns
• Requires active political mobilization,
  information and shared decision-making to become
  an effective, independent force
• Future challenges
• Should the state invest in guaranteeing an
  independent, effective PO? How? Media anti-trust
  policy citizens associations?
• Should the state counterbalance IGs media
  campaigns? How?
• A substantial public investment in data,
  information and research on PO (and
  professionals one!) is required
• Analysis of routine national series is a high
  priority

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WHO PARTICIPATES?

• ? At the aggregate level, the decision to engage
  in collective action depends on
• 1. the intensity of political conflict across
  social cleaveages (class/income, religion/values,
  community/ethnia), ideologies and political
  issues (social structuralism) and ...
• 2. the extent to which there are political
  elites/organizations who actively mobilize (and
  represent) their constituencies (power resources
  theories ? actor/action)
• 3. ... which in turns depends on the extent to
  which state policies grants equal political
  social rights to under/priviledged groups
  (policy feedbacks)
• 4. the openess of democratic institutions to
  direct political participation (institutionalism),
  eg voting regulations, neocorporatism, popular
  legislative initiative, referendum
• NOTE Olsons thesis are compatible with all the
  above