2005

Health Politics:

Lecture 10

Summary

Ana Rico, Associate Professor

Department of Health Management and Health Economics

ana.rico@medisin.uio.no

2005THE DEPENDENT VARIABLES:

Types of WS and HC systems- Policy instruments

- Impact: Social outcomes

2005

DEMOCRATIC GOVERNMENT &

INSTITUTIONS

PUBLIC & SOCIAL INSURANCE

PUBLIC WELFARE SERVICE

PRODUCTION

GOVERNANCE & POLITICS

THE MARKET

Financial markets

Product markets

INTEREST GROUPS

PRIVATE FINANCERS: Banks, insurers, citizens

PRIVATE PROVIDERS: Hospitals, doctors, schools, nursing homes

THE WS

1. THE WS, POLITICS & MARKETS: Definition

2005

EGALITARIAN Outcomes REGRESSIVE

-

% C

overe

d

+

2 & 3. TYPES OF WS : Instruments and consequences

Pure (unmixted) Socialdemocratic

UNIVERSAL

RESIDUAL

Pure liberal: Public insurance for the poor

Pure Christian Democratic: Employees

Pure ChisDem: Non-employed

Pure CD: Private insurance for employers

Pu

re liberal: P

rivate insurance

for the n

on-poor

Based on Esping-Andersen, 1990

2005

Source: McKee, 2003

2005

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

2005

HC in CRISIS: Canada & US

2005

HC IN CRISIS? Canada, gov. approval

2005

THE INDEPENDENT VARIABLES:- The political sysem

- Context, actors, instits. , action

2005

a. Demands and supportsb. Access to the political systemc. Decision-making

d. Institutional changee. Impact of policyf. Distribution of costs and benefits

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

Policy change

INPUTS

Outcomes

THE POLITICAL SYSTEM

POLICY (SUB-) SYSTEM

a c

d e

b

OUTPUTS

Outputs

POLICYPOLITICSPOLITY

f

HC SYSTEM

Political, policy/sociopolitical and social systems SOCIAL CONTEXT

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

Interactions:• Coalitions/competit.• Leadership/strategy

Sociopol. actors:

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

CONSTITUTION

CULTURE

* Org.Struct.

* Subcultures /pol.identities

* Ideologies * Ideas

Social organiz. • Associations • Churches• Firms

Social groups - Communities- Ethnia, gender- Social classes

2005

$

The social context

The political game

HC SYSTEM

The socio-political context

Policy

MACRO: Political actors

MESO: Sociopol. actors

MICRO:Social actors

Citizens’ Associations

Political parties’ members IGs

- Bussiness - Insurance

Profes. + providers’ Assoc.

Patients’ Assoc. Patients’

Advisors and managers

2005

ACTION-CENTERED THEORIES. 1.1. RQs

Social context

Policy context

State context

RQ 1. Who participates? (= seeks to influence policy)

RQ 2. Who influences policy?

REPRESENTATIVE DEMOCRACY “DIRECT” DEMOCRACY

RQ 3. Who governs?

RQ 4. How it governs?

2005THE THEORIES:- Concepts

- Hypotheses- Causal maps

2005

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

CONCEPTS (4): The state

2005

SOCIAL PRESSURES OLD INSTITUTIONALISM Formal political institutions

SOCIAL ACTORS (IGs: dependent on

social pressures)POLITICAL ACTORS (STATE: independent

of social pressures)

SOCIOP. ACTORS (STATE-SOCIETY: interdependent) NEW INSTITUTIONALISM

(state institutions & state/PPs/IGs’ organization)

POWER-CENTRED THEORIES (interactions among collective actors & social structure)

RATIONAL CHOICE (interactions among individuals

ACTOR-CENTERED INSTITUTIONALISM (interactions among institutions & elites)

1950s/60s: SOCIAL CONTEXT

1970s/1980s: ACTOR-CENTRED

1990s: INSTITUT-IONALISM (+state-society)

2000s: ACTION THEORIES

SOCIAL & POLITICAL THEORIES

L3

L5L2, L4

L6

L7

L9L4, L9

L7

L7, L9

2005

CAUSAL MAPS

Government action/Policy change

Source: Orloff & Skocpol, 1984

State formation (bureaucratization, democratization

Socioeconomic & cultural changes

Changing class structure & new social needs

Proposals of politically active groups

How state organizations & parties operate

Changing group and social needs

What politically active groups propose

Government action/Policy change

Social context & social actors theories

State-centered theories

2005

CAUSES OF THE WS

Based on Esping-Andersen 2000 & 2003; Jenkings & Brents 1987; Skocpol 1987

Policy change

Social structure

Christian & conservative parties, insurers, unions & voters

Socialdemocratic parties, unions & voters

Coalition formation & Political competition

* Electoral campaigns * Policy campaigns

Dominant national subcultures

Liberal parties, progressive (state) elites, social protest

SOCIAL POLITICAL POLICYSOCIOPOL.

2005

THE THEORIES (2):- Old and new debates

2005

SOCIAL vs. POLITICAL THEORIES

Bussiness associations & Unions

Professional associations

Policy experts

Citizens´ preferences (= PO)

Mass media

Social movements

““FATE”FATE”

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

CHANCECHANCE

CHOICECHOICE

INTERESTGROUPS (as delegates of social groups dependent on mandate)

POLITICAL ACTORS (as representatives) independent of social groups

SOCIOPOLIT. ACTORS interindependent

2005

PREFERENCES POWER ACTION

ACTOR-CENTRED

THEORIES (state-

centric/state-society)

Public interest

(officials’ autonom.

prefs./socioP infl.)

State/SocioP

capacity: inst + fin

+ know + CA res.

Autonomous/

Dependent on

socioP influen.

INSTITUTIONAL

THEORIES

Institutional norms

& values

Formal institutions Induced –

‘socialized’

RATIONAL CHOICE

Game theory

Private (self-)

Interests

Financial

Resources

Strategic

ACTOR-CENTRED

INSTITUTIONALISM

Ideas, interests &

institutions

Instit. (+ fin &

know) resources

Strategic/

Induced

POWER-CENTRED

THEORIES

Resources

(ideas), interests

& ideologies

Fin + know +

instit + org. + CA

resources

Strategic/

Dependent

on socioP infl.

ACTORS & ACTION ACROSS THEORIES

2005

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...

Rational choice Power-centred theories• Individuals

• Interests• Resources $• Competition

• Social groups• Power resources• Collective action• Coalitions

Institutionalism• Organizations• Rules & norms• Expectations • Formal power

Rational models

Incremental models

Interaction models

ACTION-CENTERED THEORIES

2005TOWARDS 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

2005CAUSES OF POLICY CHANGE:

Operationalization in WS/HC research

Adapted from Walt and Wilson 1994

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

CONTEXT

INSTITUTIONS

POLITICS: Strategies, Interactions

Individual and collective

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

• Sociopolitical structure:• Cleavages and political identities

• Values: Culture and subcultures

-

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

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

Conjunctural factors: ec crisis, wars

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

POLITICAL ACTORS

Preferences

ResourcesFormal and informal

2005EVIDENCE: DETERMINANTS OF

WS EXPANSION

2005

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

EVIDENCE

2005

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

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

EVIDENCE

2005

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.)

EVIDENCE

2005

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

Left vote

WS expansion

ACTION-C. THEORIES. 4. Evidence

2005

A. Power-centred theory: Hichs & Mishra (cont.) :

RESOURCES PRO-WELFARE ANTI-WELFARE

Political-CA resources Central government

Interest organization

Political mobilization

Voting mobilization

Left & (ChD) center parties

Organized pro-W group activism

Social protest (lower classes)

Newly mobilized voters

Right parties

Organized a-W group activ.

Direct action (upper classes)

Low voter turnout

Institutional resources Territ. centralization

Statutory access of Igs

Unitary countries

YES: Left corporatism

Federal/devolved countries

NO: Pluralism

Financial resourcesState fiscal & fin. capacity

State involvmnt as

producer

High profit rates, inflation (?)

High revenue as % of GDP

High public as % tot employment

Low profit rates, deflation

Low revenue as % GDP

Low % public employment

Policy legacy-social

learning–national culture

High status civil service,

collectivism, equity

Corrupted bureaucracies,

individualism, freedom

ACTION-CENTRED THEORIES. 4. Evidence

2005THE FUTURE: THE BATTLE FOR PUBLIC OPINION

IN HEALTH POLITICS

2005

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.

2005

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

WHY IS RELEVANT? (2)

2005

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

WHY IS RELEVANT? (3)

2005

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

DETERMINANTS

2005

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?

2005

DETERMINANTS OF SUPPORT FOR STATE INVOLVEMENT,

24 OECD countries, ISSP 1997

PUBLIC UNEM. POLICY PUBLIC HC

INDIVIDUAL LEVEL

Woman .15* .09*

Age .004 .02*

Unemployment .36* .03

Egalitarian ideology .76* .37*

NATIONAL LEVEL

Unemployment .17* .12*

National ideology .29* .03

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.

2005

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

2005

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

WHO PARTICIPATES?