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Health Politics: Lecture 10 Summary

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Title: Health Politics: Lecture 10 Summary


1
Health PoliticsLecture 10Summary
  • Ana Rico, Associate Professor
  • Department of Health Management and Health
    Economics
  • ana.rico_at_medisin.uio.no

2
THE DEPENDENT VARIABLESTypes of WS and HC
systems- Policy instruments- Impact Social
outcomes
3
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
4
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
5
Source McKee, 2003
6
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

7
HC in CRISIS Canada US
8
HC IN CRISIS? Canada, gov. approval
9
THE INDEPENDENT VARIABLES- The political
sysem- Context, actors, instits. , action
10
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
11
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
12
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)
13
THE THEORIES- Concepts- Hypotheses- Causal
maps
14
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

15
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)
16
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
17
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
18
THE THEORIES (2)- Old and new debates
19
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
20
ACTORS ACTION ACROSS THEORIES
21
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

22
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

23
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
24
EVIDENCE DETERMINANTS OF WS EXPANSION
25
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

26
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

27
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.)
28
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
29
ACTION-CENTRED THEORIES. 4. Evidence
A. Power-centred theory Hichs Mishra (cont.)
30
THE FUTURE THE BATTLE FOR PUBLIC OPINION IN
HEALTH POLITICS
31
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.
32
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

33
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

34
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
35
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?

36
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.
37
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

38
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
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