Welfare states and health care systems Lecture 2

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Welfare states and health care systems
Lecture 2

• Ana Rico

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STEPS IN INDUCTIVE POLICY RESEARCH

• DESCRIPTION
• Definition of the WS
• Types of welfare states and health care systems
• - Which are the relevant policy instruments in
  each sector?
• Evolution trends
• - Do different types evolve differently (diverge)
  or similarly (converge)?
• ANALYSIS
• Causes determinants
• - Economic (e.g. industrialization, GDP growth),
  social (e.g. Illness, poverty, social structure),
  and political (e.g. voting, government
  coalitions)
• Consequences social, economic and political
  impact
• - Which impact upon poverty, health,
  unemployment? National/by social group
• Policy implications
• - Which policy instruments should be selected in
  each country and sector, given the national
  configuration of causes, and the evidence on
  their consequences?

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OUTLINE OF THE SESSION

• INTRODUCTION
• THE WELFARE STATE (Esping-Andersen, 2000 2003)
• 1. Definition and measurement
• 2. Types of WS in Europe Policy instruments
• 3. Consequences/outcomes
• 4. Causes of the welfare state origin and
  evolution
• NATIONAL HEALTH CARE SYSTEMS (Blake Adolino,
  2001)
• Types Beveridge, Bismark, (Shemashsko),
  Residual/market-based
• 5. Evolution and policy instruments
• 6. Determinants
• 7. Policy implications

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1. THE WS Definition and measurement

• Definition
• Role of the state in the protection against life
  risks A big public insurance company (Social
  Security), which also owns, or contracts with, a
  service provision company/ies (eg the British
  NHS)
• It usually includes
• - Cash benefits old age, unemploym., sick leave,
  maternity pensions
• In-kind benefits or welfare services HC, social
  care, education
• But when is protection against risks extensive
  enough for an state to be called welfare state?
• Initially only states with universal, free
  programmes (Briggs 1969)
• Later most civil servants work in welfare
  (Therborn 1983, quoted by Esping-Andersen 2000)
• Nowadays At least 3 nearly universal programmes
  Mahoney (2004)
• WS regimes role of state/market/family in
  protection from risks

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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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1. THE WS Definition and measurement

• Measurement
• Quantitative indicators expenditure (per hab. or
  GDP), employment
• Qualitative indicators nature of entitlement
  (poverty, employment, citizenship),
  decommodification ( universal benefits
  independent of employment or income), coverage (
  population), generosity of benefits, number of
  programmes covered
• Types of WS
• Different types of WS depending on
  values/ranking in quantitative and qualitative
  dimensions
• Causes of WS Main theses nowadays
• Different types of WS (HC systems) have different
  causes
• Different WS sectors (eg pensions, HC) can be of
  different types, and have different causes

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1. 2. THE WS, Measurement Types
Conservatism
ITA
AUS
GER
BEL
FRA
FIN
IRE
JAP
NZ
NOR
NETH
UK
CAN
USA
SWE
DNK
AUZ
SWI
Neo-liberalism
Socialdemocracy
Based on Hicks Kenworthy 2003
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2 1. TYPES OF WS Types and policy instruments
(THREE 1) WORLDS OF W CAPITALISM?
(Esping-Andersen 1999)
PUBLIC EMPLOYMENT AS A OF TOTAL ( STATE
PRODUCTION)
SOUTH-EU (1)
PUBLIC SOCIAL EXPENDITURE AS OF TOTAL (
PUBLIC INSURANCE)
SOUTH-EU (2)
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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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2 3. TYPES OF WS Instruments and consequences
I. THE SOCIAL DEMOCRATIC WORLD

• 1. Policy instruments
• Redistributive financing benefits
• Universal access (citizenship)
• Public provision of services
• Expanded services, active labour mkt
  gender-egalitarian policies

• 2. Policy (outputs ) outcomes
• Public expenditure High (output)
• Income ? Poverty class inequality
• Employment ? gender class inequality
• Main beneficiary poor citizens/residents
• working women

• II. THE CONSERVATIVE (CHRISTIAN DEMOCRATIC) WORLD

• 1. Policy instruments
• Proportional financing benefits
• Profess. groups (employm.-based)
• Private (NFP) provision of services
• Cash transfers across life cycle

• 2. Policy (outputs ) outcomes
• Public expenditure High (output)
• Income ? inequality of workers at risk
• Employment ? total levels of employment
• Main beneficiary middle-class families

III. THE LIBERAL WORLD

• 2. Policy (outputs ) outcomes
• Public expenditure Low
• Income ? Extreme poverty, ? inequality
• Employment ? total levels of employment
• Main beneficiary PUB poor/old citizens
• PRIV the wealthy

• 1. Policy instruments
• Regressive financing benefits
• PUB Redistr. PRIV regressive
• Means-tested (income)
• Private (FP) provision of services

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2. TYPES OF WS
THE 3 WORLDS OF WELFARE CAPITALISM National
configurations of Social structure
Distribution of power, income, rights, status
across social groups ? Political ideologies (or
subcultures)? Partisanship (party/ies in
government) ? WS Policy instruments ? Policy
outcomes by social group (distributional
consequences)
The social demo-cratic world
The conservative world
The liberal world
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4. CAUSES OF THE WS

• Initially, Esping-Andersen theory was
  actor-centred (political parties)

• As a reaction to social determinism in early
  marxist theory

• In the 2000s, his theory becomes action-centred
  (and multi-causal)
• - what matters is not whether SD present in
  government, but
• - how they played the political game
  mobilization in the streets, coalition with
  middle-class parties, success of their prior
  policies

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4. CAUSES OF THE WS Origin and evolution
Christian conservative parties, unions voters

• Political competition Electoral
  campaigns Policy campaigns
• Political mobilization
• Coalitions

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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4. CAUSES OF THE WS Origin and evolution
Based in Esping-Andersen 1990 2003
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4. CAUSES OF WS Origin and evolution

• Action-centred arguments
• National culture is not given, but rather a
  consequence of politics
• The socialists were a main cause of the WS, even
  when not present in government (state actor) ?
  still influential as a pressure (sociopolitical)
  group, via political mobilization
• When in government, coalitions with other actors
  critical to explain success in WS development
• CONCLUSIONS Main theses
• National cultures and WSs result from political
  struggles among ideological subcultures
  represented by competing coalitions, by which one
  became predominant over (but didnt eliminate)
  the others
• In each WS subsector, an specific combination of
  conservative, liberal and socialdemocratic policy
  instruments exist, which is the result of the
  varying success of different competing coalitions.

Based in Esping-Andersen 1990 2003
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4. CAUSES OF THE WS Evolution

• The increasing interpenetration among the 3
  worlds
• 1. A common conservative historical origin
  (Ancient Regime, absolutism)
• Characterized by (church) charity for the poor
  guild-type mutual funds for the employed
  extensive welfare role of family (women)
• Which became predominant in countries with weak
  liberal socialdemocratic subcultures the
  ChrisDem reform path, SHI crowds-out most private
  market
• 2. A competing liberal reform path (emerging in
  1900-30, back in 1980-90s)
• Initially oriented to undermine Conservatism
  public system substitutes charity and markets
  substitute mutual funds
• Initially wins the battle in Anglosaxon, then
  Scandinavian countries
• Later oriented to undermine socialism slowly
  penetrating rest of the world
• 3. A socialdemocratic reform path (emerging in
  1900-30, dominant in 1945-75)
• Which aimed first at removing 1. Unions ( then
  the state) take over charity
• And then competes with 2. The state takes over
  the private market too
• Varying penetration across EU dominant in
  Nordic, SouthEU, UK NHS, CEE.

Based in Esping-Andersen 2003
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THE US EXCEPTION

• In WS cash transfers, similar to conservative
  model (if less generous)
• In HC, liberal ? very limited role of the state
  (less than 50 of pop.)

• 1930s Succesful pro-poor WS (cash transfers)
  reform BUT failed health care reform ? 1. Success
  WS 2. Failure HC
• Europe 1880-1920s pro-poor WS HC
• 1960s-1970s Succesful pro-workers pension
  reform, limited unemployment reform, and very
  limited (pro-poor aged) health care reform ? 1.
  Partial success WS 2. Limited success HC
• Europe 1945-70s ? Universal or pro-workers WS
  HC (but Switerland, pro-workers HC in 1999)
• 1993-4 Failed universal health care reform ?
  Failure HC
• Europe 1970s-90s ? Further expansion of WS
• From pro-workers to universal in CD WS
• New programmes (eg social care) in SD WS

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Source McKee, 2003
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5. NATIONAL HEALTH SYSTEMS Evolution instr.
Based on Immergut E (1991) Medical markets and
professional power The economic and political
logic of government health programmes, Working
Paper 1991/24, Center for Advanced Studies in the
Social Sciences, Juan March Institute, Madrid,
Spain.
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6. DETERMINANTS OF NHI REFORM

• Cultural explanations
• National culture (stable) Liberalism/individualis
  m in Anglosaxon countries a distrust of
  government solutions to societal problems
• Economic explanations (Convergence th) omitted,
  controlled by design Does not explain
  differences among developed countries US
  exception
• Institutional explanations
• A. Executive dominance Parliamentary systems
  feature stronger party discipline..., and greater
  centralization of legislative authority in the
  cabinet
• B. Federalism
• C. Corporatism (as an indicator of interest
  groups formal political power)
• Political explanations (political actors and
  political action)
• Strong left political parties in government
• Public opinion omitted from the analysis (see
  pp. 689-690)
• Interest groups omitted, the uneven success of
  IGs in blocking NHI points to the need to model
  the nature of IGs group politics
• Political leadership, strategy, policy model
  ommitted (see pp.702-3)

From here on Based on Blake Adolino 2001
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6. DETERMINANTS OF NHI REFORM QCA measurement
Supportive culture Unitary Executive
dominance Left rule Corporatism
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6. DETERMINANTS OF NHI REFORM Analysis

• In the most generous WS, all 5 causes present
  NOR, SWE
• Given a supportive culture, a left party, and a
  corporatist pattern of IGs intermediation, NHI
  enacted even if unfavourable political
  institutions
• AUS, DEN, FIN, BEL, GER, NETH
• 3. Unitary states with supportive cultures,
  enacted NHI even if rest of conditions
  unfavourable
• ICE, FRA, ITA, JAP
• 4. Anglosaxon countries with a dominant
  executive and left parties enacted NHI in spite
  of rest of factors unfavourable
• UK, IRE, CAN, AUSL, NZ
• 5. Causes of American excepcionalism The USA
  is the only country with unfavourable
  conditions in all 5 vars.

MAIN CONCLUSION To date, the absence of
favourable (political) institutions has only
been overcome by the simoultaneous presence of
all three other supportive factors (culture,
labour party, corporatism)
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7. POLICY IMPLICATIONS FOR THE USA (pp. 702-3)

• A. Reform political institutions
  (institutionalists)
• Unlikely, rules of constitutional revision very
  tough
• ? OK for Executive dominance and Fedralism, but
  what about party discipline (part of E) or
  corporatism (C)?? NOTE C defined as an
  institution, but in the discussion treated as a
  sociopolitical actor (Unions)
• B. Mobilize political support (action-centred)
• Need for the (1) Democratic party to overcome
  internal divides progressive statists (similar
  to SD) mixed with liberals/conservatives
• ? NOTE Amenta (2004) on North/South divisions
  within D party
• Need to develop strategies for (2) influencing
  public opinion, so that a supportive culture can
  develop (3) mobilizing sociopolitical actors
  (e.g. citizen associations, social movements)
  which could play the role of unions
• ? NOTE Briggs (1961) on USA 1935 SS Act and UK
  1945 NHS