Health Politics: Lecture 10 Summary

1. Health Politics:Lecture 10Summary Ana Rico, Associate Professor Department of Health Management and Health Economics ana.rico@medisin.uio.no

2. THE DEPENDENT VARIABLES:Types 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. POLITY POLITICS POLICY Political, policy/sociopolitical and social systems SOCIALCONTEXT 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 CONSTITUTION HC SYSTEM Social groups - Communities - Ethnia, gender - Social classes • Interactions: • Coalitions/competit. • Leadership/strategy • 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 MICRO:Social actors The social context

12. State context Policy context Social context ACTION-CENTERED THEORIES. 1.1. RQs REPRESENTATIVE DEMOCRACY “DIRECT” DEMOCRACY RQ 3. Who governs? RQ 2. Who influences policy? 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 2000s: ACTION THEORIES POWER-CENTRED THEORIES (interactions among collective actors & social structure) 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 SOCIOPOL. POLITICAL POLICY 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. 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 TOWARDS TWO MAIN THEORIES? 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 POLITICAL ACTORS INSTITUTIONS 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 = citizens’s 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 cause=input of HC reform for policy-feedback theory

34. DETERMINANTS • Interests: social structurevs. 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: Olson’s thesis are compatible with all the above