Welfare State Restructuring And Policy Feedbackpaperroom.ipsa.org/papers/paper_12212.pdf · Welfare...

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Welfare State Restructuring

And Policy Feedback

Anna Bendz

Department of Political Science

University of Gothenburg

Box 711

405 30 Gothenburg

Sweden

[email protected]

This paper is in a preliminary stage, please do not cite. All comments welcome!

Prepared for presentation at XXII World Congress of Political Science (IPSA).

Madrid July 8-12, 2012

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Introduction

Welfare policies have consequences. Not just in terms of outcomes like the number of patients treated

by hospitals, the quality of education or how many senior citizens get help from home service.

Welfare policies also have consequences for mass opinion such as perceptions of the welfare state and

government in general, political action, and trust. Peoples’ experience with the welfare state transfer

into opinion and behaviour that is at the heart of democratic functioning. The growing research

tradition of policy feedback captures the relationship between policy (or institutional design) and mass

opinion by seeking to clarify how policies are likely to affect political thought and action in the

citizenry. Research on policy feedback-processes thus clarifies how public policy matter for the

vitality and function of democratic politics (Mettler & Soss 2004).

This paper takes it’s empirical point of departure in the contemporary and ongoing changes of the

Social Democratic Welfare State, with focus on the restructuring of the welfare service sector in

Sweden. The change of the welfare state service arena refers to the New Public Management-inspired

policy aiming to achieve a more efficient and responsive public service sector by creating competition

between different providers of welfare services. As a result, the welfare service sector becomes more

market-like with private and public actors competing to attract the ”consumers”.

For the Social Democratic Welfare states and its citizens, this is a significant change since one of the

most defining features of this type of regime is that it provided public welfare services on a totally

different scale than all other countries outside Scandinavia (Lindbom 2001, Esping-Andersen 1999).

Additionally, Social Democratic welfare states traditionally builds on principles of universality and

entitlements which is in conflict with the market principle of relying on effective demand to bring

forward service supply (Taylor Gooby 2004). Thus, this policy re-orientation challenges one of the

core values of this kind of welfare state, social equality (Bendz 2012).

The general argument in this paper is that the changing character of the Social Democratic welfare

state has implications for the relationship between state and individual since the terms of the social

contract is re-negotiated in several welfare service areas. Instead of being a more or less passive

service recipient, citizens are expected to take responsibility over their welfare in a more active way

by making good and informed (rational) choices according to their preferences. This, in turn, is in this

paper assumed to have consequences for public opinion. By focusing on the connection between

policy and public opinion, the ambition in this paper is to contribute to the growing literature on policy

feedback effects that aims to bridge the gap between policy analysis and research on mass opinion.

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Why would market-oriented welfare reforms have consequences for public opinion? The key

mechanism put forward here is that the policy-reorientation is tipping the power-balance between state

and individual by empowering the citizens. Empowerment is in this case created by allowing freedom

of choice for the citizens in the welfare service area, by giving the opportunity to choose from an

increased number of available service producers. This means two closely related things: that citizens

may choose an alternative according to their preferences, and that they have the possibility to exit

from this alternative and choose another one if they are not content. The presence of exit options has

been showed to generate positive welfare state experiences, which in turn generates support for the

welfare state (Kumlin 2004). Also, such positive experiences seem to have spill-over effects to

opinions about the government and politics in general (Soss 1999).

This paper focuses on one specific case, and thereby it differs somewhat from most previous research

on policy feedback effects of welfare policy and/or institutions, which have mostly had a comparative

design. The empirical case in the paper concerns the implementation of a consumer’s choice model in

Swedish primary health care in 2009/2010. The reform allows private and public providers of primary

health care to compete on equal terms for clients, financed by tax money (see further below). I argue

that this reform is a most likely case for policy feedback effects because of its high visibility and

proximity (Soss & Schramm 2007, Pierson 1993. See also further below).

The aim of this paper is to elaborate on the correlation between institutionalised empowerment and

public opinion by analysing which consequences for welfare attitudes that follows from the

implementation of consumer’s choice in Swedish primary health care. Do experience from

institutionalised empowerment in one welfare service generates a) contentment with the service and b)

support for the market-orientated restructuring of the welfare service area in general? This, in turn,

would implicate that the institutional design of welfare services can contribute to the reinforcement

and stabilization of a certain welfare policy through creating popular support.

In the next section of the paper, policy feedback and empowerment in the welfare state context is

discussed as a theoretical frame of analysis. After this, the Swedish case is introduced by a description

of the contemporary changes of the welfare state service sector. A brief design and method section is

then followed by results and a final discussion.

How and why public policy matters for public opinion

A key insight from policy feedback research is that public policy matter for the vitality and function of

democracy by affecting how people think and act as members of a community. Thus, policy is not

only output of political decisions, but also inputs that create frames and structures that not only affect

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costs and benefits associated with future political decisions but also peoples’ incentives and

perceptions which in turn influence political action (Pierson 1993). By connecting research on public

policy and research on mass opinion, it is possible to assess the democratic consequences of policy as

well as contribute to the understanding of mass political behaviour (Mettler & Soss 2004).

Policy feedback is from the start associated with historical institutionalism, where policy feedback

refers to how existing policies affect politics and policy development over time. The research focused

on for example state building, interest group formation and lock-in effects (Pierson 1993, Skocpol

1992, Hall & Taylor 1996). The topic in this paper connects to one of the more recent strands in the

research on policy feedback where the focus is on how policies affect beliefs, preferences and actions

of mass publics where scholars explore the relationship between policies and political participation

and attitudes (see e.g Béland 2010, Mettler & Soss 2004, Soss 1999, Soss & Schram 2007, Campbell

2003, Svallfors 2010, Mau 2003).

The empirical research in this part of policy feedback-inspired research has a certain emphasis on

welfare policies. Soss and Schram (2007) points out welfare reform as a promising case to advance the

policy feedback research field since welfare reform can be seen as a ”most likely”-case for feedback

effects: “In short, welfare reform offers a case in which predictions of mass feedback seem both

plausible and amenable to testing” (p 114). The reason is that welfare policies is important to many

people and also that many have experience from one or several welfare programs during their lifetime,

even though this varies greatly across countries. In Sweden, it is hard for citizens not to have quite a

lot of experiences of the welfare state because of its size and scope. This fact can be argued to make

Sweden one of the most interesting cases among welfare states if one wants to investigate the effects

of welfare policy in general.

What does public policy affect and how?

In an article by Mettler and Soss (2004) on policy feedback as a research area, policy is suggested to

have effects on “political thought and action”, but also “what individuals think, feel and do as

members of the polity” and how public programs shape “citizens’ beliefs, preferences, demands, and

power” (Mettler & Soss 2004). In other words, policy feedback effects on mass opinion can be

expected to be found in a very broad range of human reactions to public policy.

What aspects of mass opinion that is affected by public policy is not a fixed set but rather defined by

the researchers interest and also, of course, tried and shown in empirical studies. Some examples:

Campbell (2003) showed that elderly citizens that participate in US Social Security get more inclined

to electoral participation, and that this participation then affects the politics of Social Security in

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significant ways. Soss (1999) explore the links between welfare participation and political

involvement. He shows that the design of welfare programs lead to different beliefs about if it is

efficient to make demands in the programs and different perceptions about one’s own ability to

understand and participate in political life. Solevid (2009) investigates how institutions constitute the

relationship between evaluation of public service and political action and shows that the degree of

empowerment is important for the extent to which dissatisfaction with services translates into political

action. Kumlin (2004) shows that institutionalised empowerment leads to general trust in the political

system and in politicians.

As the above examples show, policy feedback effects can be assumed to occur (and be measured on)

different levels or distances from the policy that is assumed to have effects on mass opinion. Just like

the rings spreading outwards when throwing a stone in the water, feedback effects can spread further

away from reactions on the specific policy area or group of policy areas to reactions to the political

system in general. As Soss (1999) points out, for many people welfare experiences serve as their most

direct source of information about how government works. Thus, welfare program users use their

experiences to draw inferences about government in general, for example of the government’s

responsiveness or their own ability to participate in political life. The conclusion is that welfare

programs are sites of political learning: Clients interpret their experiences with welfare bureaucracies

as evidence of how government works in general (Soss 1999).

In some of the previous research in this area, the research question emanates from an ambition to

explain a certain output by using policy feedback approaches, for example social trust (Larsen 2007).

In other, the interest lies in a particular correlation, for example how welfare state retrenchment affects

perceptions of how well democracy works (Kumlin 2010) or how citizens’ aggregate policy

preferences contribute to welfare state persistence (Brooks & Manza 2006). In this paper, the

research interest lies not in explaining a particular dependent variable, nor in elaborating on a

particular correlation. Instead, I ask the question in a more open manner, departing from the

assumption that the policy changes in the Swedish welfare state should have at least some effects on

some of the factors in the possible range of reactions. This assumption emanates from that welfare

policy is pointed out as particularly likely to generate feedback effects, but also from the nature of the

policy that is in focus here. The restructuring of the welfare state in Sweden is assumed to give rise to

what Paul Pierson have named as interpretive effects, that is impact on cognitive processes meaning

that peoples’ opinions, preferences and actions are affected by policy design (Pierson 1993).

Soss and Schram (2007) suggest a general framework for analysis of mass feedback processes. For

this they use two dimensions. Visibility refers to the degree to which a policy is salient to mass publics.

Proximity refers to the direct versus distant form in which a policy is encountered. High proximity

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means that people have individual experience of a policy or program. These dimensions are put

together in a two by two matrix. The proposition is that the relationship between public policy and

mass opinion will proceed according to different logics depending on a policy’s location on the

dimensions. A policy with low proximity and low visibility will not very likely influence mass opinion,

while a policy that has high proximity and visibility will have the greatest potential for policy

feedback effects on mass opinion.

Following this framework, I argue that the reform studied in this paper is characterized by high

proximity and high visibility for most people, which mean that it is reasonable to expect feedback

effects on public opinion. Most people, or their close relatives, uses a health care centre more or less

often in their lives, thus most people have a direct experience of health care centres. Recent figures

from a national survey show that about 80 % of the Swedes have been in contact with a health care

centre, either themself or a close relative. The health care reform is also highly visible one: not only

are health care in general pointed out as one of the most important areas by the Swedes, the reform

itself was also quite visible in the media especially at the time of the reform’s introduction. This kind

of policies should, according to Soss and Schram, produce feedback effects by the cues they convey to

broader mass audiences either through the policy’s direct impact on peoples’ lives or from it’s

symbolic meanings (Soss and Schram 2007).

Empowering the people

The most tangible consequence of the contemporary restructuring of the welfare service sector in

Sweden is that citizens are given the possibility to choose from a range of private and public service

providers. In other words, the welfare service sector empowers people to a higher extent than before,

foremost by allowing exit options. Empowerment is in this paper seen to be the mechanism that links

public policy to public opinion, that is the mechanism through which feedback effects operate (Solevid

2009).

Empowerment as a concept refers to the power balance between the state and the individual citizens.

The higher the degrees of influence over one’s life circumstances, the higher the degree of

empowerment. Building on Hirschmanns famous distinction there are two main strategies to create

empowerment: Exit and voice. Exit means that people, when dissatisfied with a government or a

public policy, can choose an alternative by for example voting for a new party on election day or

choosing another school for their children if they are not happy with the present one. Exit options are

present whenever there are alternatives. Voice means to try to change things within the existing

alternative instead of choosing another one (Hirschmann 1970).

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In the welfare state context, exit-options refer mainly to the presence of one or several other

organizations – public or private- that offers comparable service. Since it can be assumed that public

agencies as well as private companies want to keep their clients, bureaucrats should be more likely to

listen to complaints and preferences if there are exit-options. In this way, exit-options make the power-

balance lean over to the citizens (Hoff 1993, Kumlin 2004). The knowledge that exit options exist can

be argued to strengthen individuals’ autonomy and general self-confidence in their encounters with the

welfare state. Thus, possibility of exit strengthens the power balance in favour of the individual

through mechanisms of autonomy and self confidence (Solevid 2009).

Primary health care is in Sweden a universal welfare service with a non-discretionary character in the

sense that access is not granted on economic grounds, that is that citizens is granted access to health

care depending on their ability to pay or that they get access to public health care because of poverty.

Universality can in itself be seen as a dimension of empowerment. Empirically, it has been proved that

citizens in programs with a universal (non-discretionary) character are more positive towards the

welfare state than citizens that have experiences from a program where public officials have

discretionary power (see for example Rothstein 2010).

Welfare institutions can be categorized according to the degree of empowerment. Kumlin (2004) and

Solevid (2009) both show empirically that there is a difference in effects on public opinion and

behaviour depending on if citizens have experience from institutions with high or low institutionalized

empowerment. Institutions with higher levels of institutionalized empowerment generate positive

effects on public opinion, while institutions with lower levels of institutionalized empowerment

generate negative effects. The Swedish primary health care system was by these researchers

categorized as an institution with limited or medium exit options. This was true before the 2010

reform (se below), but an important consequence of this reform is that exit options have increased for

at least the majority of the Swedish citizens. As already mentioned, exit options vary geographically.

In other words, primary health care has moved closer to the consumer or customer type of institution.

This change is a point of departure for the empirical analysis in this paper.

Following previous research on empowerment and it’s effects on public opinion, it is possible to

assume that the change of the primary health care in Sweden from a system with medium exit options

to a system with extensive – or at least better – exit options should lead to positive welfare state

experiences. This in turn is assumed to generate positive feedback effects on attitudes to the specific

policy (primary health care). Additionally, empowerment is hypothesized to generate positive

opinions of the restructuring of the welfare state in other service programs. This is a way of extending

the analysis at least a bit away from the “close” reactions following a specific policy, thus contributing

to the question of generalised feedback effects. The idea underpinning this hypothesis is that positive

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experiences from one welfare service program may transfer into positive attitudes to similar policies.

The general policy underlying the reform in primary health care is to increase efficiency and freedom

of choice by allowing private companies (or non-profit organisations) to provide welfare services. For

consumer’s choice to become realistic for the citizens, it is necessary that several – and preferably

different – actors provide welfare services. The reason why experiences from choosing welfare

provider in one area should have effects on attitudes towards market-orientated reforms, is that letting

private actors in on the welfare service market is actually what creates the possibility to choose.

As Mettler and Soss points out, to develop the research area on policy feedback it is important to try to

specify how, where and when policy feedback effects occur (Mettler & Soss 2004, see also Pierson

1993). My argument is that not only could there be differences between programs with different

degrees of empowerment, but also differences in to what extent institutionalised empowerment have

effects within a specific program. The point of departure is that welfare program participants can

experience empowerment in a direct or an indirect way and this may in turn be of importance for the

effects that empowerment has on public opinion and behaviour. In this paper, this idea is tried out in a

first empirical study.

What does it mean to have direct experience from empowerment? The idea is that welfare service

users may have very different experiences even though they use the same kind of (empowering)

welfare service. If the welfare service involves customer’s choice, people can choose to participate

actively or not by making active choice or merely being placed with a designated provider. Also, there

might be geographical variations when it comes to what service alternatives that are actually available

within a reasonable distance, which in turn makes it more unlikely that people use the possibility to

exit even if they are discontent with the service. This line of thought is further discussed below.

Exit can in theory occur either to another service provider or to no alternative at all (Hirschman 1970).

An important institutional factor that determines the degree of empowerment is the presence or

absence of realistic exit options (Möller 1996). This means for example that for exit options to be

empowering, citizens should have a reasonable short geographical distance to another service

alternative. If not, it is unlikely that citizens express their dissatisfaction with the service by leaving.

Their experience of the welfare state is certainly different from residents of city areas, where there are

plenty of service alternatives to choose from. Also, the service provider is more unlikely to adjust the

service according to citizens’ preferences because of the “threat” of exit. In this paper, present or

absence of realistic exit options in terms of geographical distance is used as a way to vary exit options

within the Swedish population in order to be able to draw conclusions about the effects of exit options.

Even if there are realistic exit options, not all people choose to use them. The experience of using the

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possibility to re-make the initial choice of health care centre may enhance the effect of

institutionalised empowerment since it is a direct experience of using exit as a way to influence one’s

situation. In the empirical analysis, this is investigated by grouping people according to if they have

used the option to exit or not.

Realistic exit options presuppose not only the existence of alternatives, but also that welfare programs

are designed in a way that makes it possible for citizens to make an informed and active choice of

service provider. This means that the concept of exit options is closely related to freedom of choice

but not exactly the same (see for example Sen 1988). Exit and choice can be obstructed by for

example emotional attachment or feelings of loyalty (Sörensen 1997). This is related to the fact that

not all people wants to, or have the opportunity to, use the given freedom of choice. It is likely that the

experience of empowerment are stronger among those who actively participate in the system, in this

case by actively choosing health care centre, than among those who for different reasons do not make

an active choice. To use the possibility to choose health care centre actively indicates that the service

is important to the person. Also, it is more likely that active choosers have reasonably good

information about the system. This should generate a stronger sense of empowerment with this group,

compared to the group of persons that are passive users of the service, and thus lead to more positive

opinions. In the empirical analysis of this paper, active or passive participation in the program is tried

out as a possible factor that can mediate the effects of institutional empowerment.

Specific research questions:

Does empowerment in terms of (increased) exit options generate a) positive attitudes to the primary

health care system and b) support for the restructuring of the welfare service sector in Sweden?

Under what circumstances (if any) do exit options matter for attitudes?

- Does realistic exit options make a difference for opinions?

- Do active participants have more positive attitudes than passive?

The Restructuring of the Swedish Welfare State

The value of equality is (or maybe has been) a core value of the Social Democratic welfare model

(Esping-Andersen 1990). As a consequence of the embracement of equality as a primary value, the

public welfare sector is traditionally extensive and the private sector has been given limited space, in

order to give citizens equal access to welfare services. Access to services should, according to this

model, be based on need, not wealth. Additionally, the social services should be the same for everyone,

and because of that they have been constructed in a unitary way and provided by the public sector

(Rothstein 2010).

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The restructuring of the Swedish welfare state has been going on since the beginning of the 1990’s.

The right wing government started to open up for competition and models of consumers’ choice in

their period in government 1991-1994. This development was slowed down somewhat when the

social democrats regained power 1994-2006, but still went on. When the right wing government

coalition came to power in 2006, the reforms aiming towards competition and increase of private

actors in welfare services was again implemented at a faster pace (Hartmann 2011). This development

implies that values like consumerism, individual rights, economic efficiency and private initiative are

stronger today than a couple of decades ago. A policy re-orientation – or perhaps even an institutional

change - has taken place in the Swedish welfare state since the public sector is today to a larger extent

seen as mainly a service producer instead of an instrument of social transformation (and promoter of

social equality). This changes the role of the citizen from a passive service recipient to an actively

choosing service consumer. The citizens are thus expected to take responsibility over their welfare in

an active way by making good and informed (rational) choices according to their preferences.

The welfare program that is analysed in this paper, the primary health care system, builds on The Act

on System of Choice in the Public Sector (”Lagen om Valfrihet”, LOV) which was implemented by

the centre-right government in 2009 (government’s proposition 2008/09:29). The Act opens the

opportunity for the local municipalities to let private companies compete on equal terms with the

public sector organisations for the providing of welfare services within health care and social services.

The local authorities set the economic compensation given to the suppliers. The service is financed

publicly, through tax money.

The Act on System of Choice in the Public Sector can be characterised as a form of consumer’s choice,

which is defined by that there are at least two providers for citizens to choose between in a certain

service area (Edebalk and Svensson 2005). The general idea with consumers’ choice is that the

politicians uses the active choice making of citizens to organise the public services, instead of

deciding how these services should be organised from the top. The citizen’s own preferences and

interests affect which service providers will remain on the market. For consumer’s choice to create the

freedom of choice that is intended, it is necessary that there are several actors that compete for the

customers. The main motive for introducing consumers’ choice is to grant the citizens influence over

the welfare services, the alternative being that the state (on some level) decides on what service the

citizens get to use. To give citizens direct influence over the welfare state services is also put forward

as a democratic argument. Another argument for consumers’ choice is based on the assumption that

people are perfectly capable to decide for themselves and thus have a right to make choices when it

comes to welfare services (Kastberg 2010).

Since 2010 The Act on System of Choice in the Public Sector is applied in primary health care,

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meaning that private and public providers of primary health care are allowed to establish in the

counties, which is the local level that is responsible for health care in Sweden. The county politicians

decide the terms and conditions that the health care providers are to fulfil, and every provider that

fulfils these conditions is allowed to compete with other providers for the patients. Every county

council is allowed to determine the economic terms, including how much money the providers get for

each patient and also if the economic replacement should be higher in some areas of the county in

order to encourage providers to establish there. The citizens then get the possibility to choose between

the public and private providers available in the county (proposition 2008/09:74). The share of health

care centres that are run by private companies have almost doubled since the reform started, partly

because some of the public health care centres have been privatized, but also because of new

establishments. Since the start of this reform, 208 new private health care centres have established,

mainly in the larger city areas.

Design and method

The design of this case study builds on two kinds of comparisons in order to draw conclusions about

the effects of empowerment. First, a comparison over time where public opinion is measured before

and after the introduction of the reform. Second, a comparison between groups based different

indicators of experienced empowerment which are assumed to mediate the effects of institutionalised

empowerment. The first indicator is variation in realistic exit options, where the fact that exit options

vary across Sweden is used to compare opinions between citizens that live in local communities with

good exit options to those who live in local communities with limited or no exit options. The second

indicator is if users of health care centres have made an active choice of health care centre or not. The

third indicator differs between those who have actually chosen to use exit options and those who have

not (see further below).

The effects are measured on two levels of opinions of welfare service. First, a policy-specific variable

that measures the opinion of primary health care service in the local community. Second, the effects

on the more general support of the restructuring of the welfare state service sector is measured.

In the analysis, both users and non-users of primary health care are included. Quite few do not use

health care centres at all (about 10 %), but it might be the case that users differ in their opinion from

non-users in this case since they have a direct experience from the welfare service in question. In the

tables measuring opinions over time, the results for only users are also presented to be able to assess

differences. In the rest of the analysis, differences are commented when the results for users deviate in

a way that is interesting for the results. Also, a division into user groups are included in the regression

analysis concerning contentment with health care.

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The datasets used is the West Sweden SOM Survey from 2007, 2008 and 2010. This is a survey sent

to a random selection of citizens of West Sweden by the SOM institute, an independent survey

organisation at the University of Gothenburg. The region of West Sweden contains about 1,5 million

of the 9 million citizens of Sweden. The reason why I use West Sweden and not the nation-wide

survey is simply that in the West Sweden survey, the questions correspond better to what I need in

order to perform the analyses. For example, in this survey there are some questions directly related to

consumer’s choice in primary health care while in the national survey these questions are not asked.

That the survey do not cover the whole country is not too problematic, since many previous analyses

show that the results from West SOM-data is very similar to those generated by the nation-wide SOM-

surveys.

Before and after

Consumer’s choice was introduced (at the latest, in some regions during autumn 2009) in January

2010. This was marked for the citizens through information from the county council where citizens

were asked to choose among a list of health care centres. Information was also available through the

internet and since the reform was also discussed in media, there are good chances that citizens had

knowledge of the change.

In the analysis, data from the years 2007 and 2008 is used to measure attitudes before the reform and

from 2010 to measure attitudes after the reform. The year 2009 is excluded since the reform was

implemented in West Sweden in October that year, a short while before the survey was sent out to the

respondents. This makes it hard to interpret the answers since it is not possible to know if the

respondents’ answers refer to the old system of primary health care or the newly implemented one.

Since the access to health care already before the reform differed across the country, the division into

groups (see below) according to exit options is also used as a control variable to rule out the

possibility that the results depend on geographical differences and not the introduction of the reform.

Realistic exit options

Even though consumer’s choice in primary health care was introduced at the same time all over

Sweden, the exit options vary geographically. New health care centres have mainly been established in

the larger cities and the surrounding areas, while some regions have practically no new establishments.

This means that in some areas, exit options are realistic due to the presence of many alternatives, and

in some not since there simply are no more health care centres nearby.

This fact is in this case study used to vary exit options among the population. For this purpose, I have

noted the amount of health care centres in each local community at the start of 2012 (which roughly is

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the same as in 2010 when the survey was sent out since the majority of the new health care centres

started in 2009 or 2010) and incorporated this information in the data set, which means that every

respondent is ascribed a value depending on their access to more than one health care centre. The

variable is categorized in three groups: 1) local communities with one health care centre or two health

care centres that is far from each other. 2) Local communities with two or sometimes three health care

centres. 3) Local communities with four or more health care centres. In category 1, the exit options

are none or very limited. In category 2, the exit options are present but if a person for example has

special preferences about opening hours or what kind of specialist doctors or nurses they need, the

choices are probably limited. In category 3, there should be enough exit options to be able not only to

exit and find a similar service, but also to choose from a range of different health care centres with

different specialities and services.

While coding this information, I have also looked at maps, to try and assess the distance from other

local communities with more or less health care centres. For example, local communities in the

vicinity of the larger cities are coded as second or third group since it is reasonable to assume that the

residents have the opportunity to choose from health care centres in the larger city even if there is only

one or two health care centres in the local community where they live. Still, a word of caution about

this categorization is that it might not always reflect the circumstances in terms of exit options for the

individuals since it is hard to assess how realistic it is to for example drive to the next town for a

health care centre.

Active choice

Citizens that use welfare service where the possibility to choose is given, can also choose to be active

or not. Being active might lead to a stronger empowerment effect than being passive by not

participating in the system. Also, it is reasonable to assume that the welfare service is more proximate

to those who actively participate which should increase the likelihood of effects on opinions. In the

analysis, I use a question that measures if the respondent have made an active choice of primary health

care or not, when the opportunity was first given in 2009/2010.

Using exit options

Another factor that could possibly be of importance for the effect that empowerment has is if the

health care centre clients actually have used the possibility to exit or not. Those who have used the

option to choose another health care centre if they are not happy with the original one have direct

experience of exit and it is therefore likely to have a more positive opinion of welfare service than

those who don’t have this experience. In the West Sweden Survey this is measured by asking the

respondents if they have re-made their choice of health care centre one or several times.

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The dependent variables

At this stage I am limited to the existing data sets and the questions put there. This means that I have

looked for the questions regarding opinions on health care centres and also on welfare state

restructuring in general that is present in the West Sweden SOM datasets from 2007, 2008 and 2010.

The question that is closest to what I want to measure and also put in all data sets I want to use is the

one asking how content the respondents are with the primary health care service in their local

community. This question is a bit tricky to interpret, since contentment with the primary health care

centre could mean anything from liking the doctor you are going to that it is easy to get appointments.

But it could also mean that the respondents are happy with the organisation of primary health care

centres as a whole.

As indicators on the attitudes to the restructuring of the welfare state in general, I use three items in a

question that asks the respondents’ opinions on a number of suggestions that are present in the

political debate. The items are:

- letting private companies run elder care

- letting more of health care be provided by private actors

- invest more resources in independent (private) schools

The point of using these items is to capture opinions of the restructuring of the welfare state service

area in general, referring to the changes in who provides welfare (from public actors to a mix of public

and private actors). This is a way of measuring the more generalised effects of public policy on

opinion, although I’m not going beyond the welfare state. The reason is that this is a limited

investigation and also that since I only focus on one specific policy area and a reform that took place

very recently, it is maybe a bit far fetched to expect effects on even more general attitudes.

The results are continuously discussed and valued by including other variables and comparisons when

it is possible, as a way of strengthening or weakening the results. The analysis technique used is,

firstly, straightforward univariate and bivariate statistical analyses presented in tables and secondly,

multivariate OLS regression analyses in order to check the robustness of the results by including

relevant control variables (only for 2010).

As to the regression analyses for contentment with primary health care as a dependent variable, the

original ordinal scale variable is used. This is, of course, not unproblematic. But as the variable

includes five steps (from very content to very discontent) it can be assumed that the distance between

the values are roughly equal. One problem is the middle alternative, which is “neither content nor

discontent”. It may be the case that those choosing this alternative expresses indifference rather than

an actual opinion but as the question includes also the alternative “no opinion” (not included in the

15

analysis), this risk is after all quite small.

The attitudes towards privatization of health care, elderly care and schools are in the regression

analyses put together in an additive index as they are tightly correlated (Cronbach’s alpha = .859). The

control variables that are used in regressions are discussed below.

Results

In this section, the results from the statistical analysis are presented. First, the results from the analysis

of policy-specific attitudes are discussed, then the results from the analysis of the more general

attitudes towards privatization of welfare services.

Empowerment and policy-specific attitudes

The first section of the results deals with the policy-specific welfare attitude, contentment with

primary health care.

Before and after

Does the possibility to choose health care centre and to be able to re-make the choice if not happy

make citizens more content with primary health care? This question is investigated by analysing

contentment with primary health care in the respondent’s local community before and after the

implementation of consumer’s choice in October 2009.

Table 1: Contentment with primary health care centre service in local community, 2007-2008 and

2010. All respondents (users) Percent.

Year Content Neither content nor discontent

Discontent Sum percent/N

2007 60 (66) 22 (18) 18 (15) 100/2937 2008 63 (68) 21 (18) 16 (14) 100/2792 2010 72 (76) 18 (15) 10 (9) 100/2815

Comment: The question in the survey is: What do you think about the service in your local community on the following areas: primary health care.

Evidently, the proportion of West Swedes that is content with the primary health care is higher in 2010

than in the years before, at the same time as the discontent figure decreases. The same pattern goes for

both respondents in general and users, although users are generally more content with the service than

non-users. It is possible that this is a temporary or random variation between the years, but it is also

reasonable to assume that the consumer’s choice reform has had some effect on contentment since no

other significant reforms or other incidents have been taken place in the policy area during the time

16

period. The result from the West Sweden survey is strengthened by that the pattern looks the same

when the same analyses are performed on national data (based on a survey that was sent out to a

random selection of citizens in the whole country).


In table 2 the respondents are grouped according to realistic exit options in their local community.

Are those living in areas with good exit options more content with primary health care than those

living in local communities with none or limited exit options?

Table 2: Contentment with primary health care centre service in local community by realistic exit

option groupings, 2010.

None or limited exit options

Medium exit options Extensive exit options

Content 68 71 73 Neither content nor discontent

20 19 17

Not content 12 10 10 Sum percent/N 100/638 100/222 100/2812 Comment: The question in the survey is: What do you think about the service in your local community on the following areas: primary health care. The groups of exit options are categorized based on the number and vicinity of primary health care centres in the local communities.

Those with no or limited exit options are less content with the service than those living in areas where

there are medium or extensive exit options even though a majority also in this group is content.

Among users of primary health care, the differences are more distinct (70 percent in group with no

exit options as compared to 78 in group with extensive exit options). It is possible that the differences

between the groups that we see in 2010 is not a consequence of the differences in exit options that

comes from the implemented reform, but stems from the fact that there already before have been

differences in how content people are with primary health care in different parts of the country and

that these geographical variations correlates with the categorization into exit option-groups. For

example, the local communities of the larger cities and their surrounding areas are included in the

group with high exit options. These are areas where primary health care service was already before the

reform more developed than for example in most places in the northern part of Sweden. Varying exit

options in primary health care is thus not an entirely new phenomenon in Sweden.

An analysis shows that both in 2007 and 2008, there are differences in contentment with primary

health care between the groups, although smaller than in 2010. That the differences between the

groups are more distinct in 2010 compared 2007 and 2008 might after all mean that the exit options

does make a difference.

17

Table 3: The impact of exit options on contentment with primary health care, with control variables

(Unstandardised OLS estimates).

Variable B

None or limited exit options -.049

Extensive exit options -.138

Users/non-users .-.43***

Opinion of choice reform -.63***

Age .01***

Gender .08

Constant −16,947

Adjusted R Square .12

p< 0,01 *** p < 0,05 ** p <0,1 * Comment: exit options is a dummy variable, where medium group is used as a base category. Users-non-users is a binary variable, where those who either use primary health care themselves or have a close relative that do are added in one group. Opinion of choice reform is a binary variable (like/dislike). Age is year of birth.

So, how do these results hold when relevant control variables are included? Since women are

generally more content with welfare service than men, and elder citizens more content than the

younger, gender and age are included. Additionally, earlier results show that users of a service

generally are more content with services than non-users, also this is included. Citizens who are

positive towards consumer’s choice in health care are probably more happy with the service than those

who are negative to the reform, a variable measuring respondents attitudes to consumer’s choice in

health care is therefore included.

As we can see in the table, differences in exit options are not significantly correlated to how content

citizens are with primary health care services: those who have many health care centres within close

distance are not more content than those that have one or two. Instead, age (the older the more content),

opinion about the choice reform in health care and if you use primary health care or not seem explain

some of the variation in content.

Active choice

The next question to be answered is if there is a difference in opinion of service between those that

made an active choice of health care centre and those who did not, when the consumer’s choice was

first implemented. As mentioned above, in the fall of 2009 all citizens in the region got a letter from

the council authorities with information about consumer’s choice and a list of health care centres to

choose from. A majority, 87 percent of the users of primary health care, chose to use this opportunity.

Table 4: Active choice and contentment with service in primary health care service in the local

18

community, 2010.

Active choice No active choice Content 74 60 Neither content nor discontent

17 26

Discontent 9 14 Sum percent/N 100/2196 100/376 Comment: The question in the survey is: What do you think about the service in your local community on the following areas: primary health care. The question used for groups of active choice is: Which health care centre did you choose the first time you had the opportunity to choose? The alternative “made no active choice” is compared to the merged alternatives “chose the health care centre that was suggested” and “chose another health care centre than suggested”.

The table shows that those who have made an active choice of health care centre are more content with

the primary health care service in their local community (the result is statistically significant). A

majority of those who have not made an active choice are also content. This might mean that the

existence of choice is enough to be content – or simply that this is a group of respondents that had

been content also if the reform had not been implemented. Unfortunately, it is not possible to check

this by an analysis of previous years, since the question of active choice was for natural reasons not

included before the reform.

Table 5: The impact of active choice on contentment with primary health care, with control variables.


Variable B

Active choice -.19**



Age .01***

Gender .087

Constant −15,377


p< 0,01 *** p < 0,05 ** p <0,1 * Comment: Active choice is a binary variable (active/not active). Users-non-users is a binary variable, where those who either use primary health care themselves or have a close relative that do are added in one group. Opinion of choice reform is a binary variable (like/dislike). Age is year of birth.

The regression analysis show that the differences we see in the bivariate analysis are still significant

when control variables are added: Those who have made an active choice of health care centre are

significantly more content with primary health care service centre than others. A note of caution is that

the causal direction is not self-evident here. Those content with the service might be more inclined to

participate actively than those who are not content. An analysis shows that this is the case: 88 % of

those who are content with the service have made an active choice, compared to 79 % of those who

are not content.

19

Using Exit Options

Are the primary health care clients who actually have used the opportunity to exit more content with

the service in primary health care than those who have not? In this case, using the opportunity to exit

refers to those who did make an active choice at first, but later decided to leave the health care centre

they chose for another one. Citizens are allowed to change their minds any number of times, although

the number of people who had switched health care centre more than once was quite small (34) when

the survey was answered compared to those who changed once (426).

Table 6: contentment with primary health care service in local community, by exit or no exit, 2010

No Exit Exit Content 73 67 Neither content nor discontent

18 17

Discontent 9 16 Sum percent/n 100/2328 100/413 Comment: The question in the survey is: What do you think about the service in your local community on the following areas: primary health care. The question used to categorize exit groups is: Did you during the last year choose a new health care centre? No/Yes, once/Yes, more than once. The two “yes”-alternatives are merged in the table.

The difference between the groups is small but significant. In this case there is obviously a risk of

reversed causality: those not happy with the service over all, almost certainly use the possibility to

change health care centre more frequently than those that were content from the start. It may be the

case that their answer relates to their experience from the first chosen health care centre. An analysis

shows that those who are not content with the primary health care more often chooses to exit (22 vs

16 %). The result is confirmed in the regression, where those who have used the option to exit are not

more content than those who have not (table 7).

Table 7: The impact of exit on contentment with primary health care, with control variables.


Variable B

Used exit-option -.11



Age .01***

Gender .085

Constant −14,915


p< 0,01 *** p < 0,05 ** p <0,1 * Comment: exit options is a dummy variable, where medium group is used as a base category. Users-non-users is a binary variable, where those who either use primary health care themselves or have a close relative that do are added in one group.

20

Opinion of choice reform is a binary variable (like/dislike). Age is year of birth.

Empowerment and attitudes to the restructuring of the welfare state

The second part of the result section deals with the assumption that people with experience from

empowerment are more positive to the restructuring of the welfare state in terms of private actors in

the welfare service arena than others. But first, a comparison of the attitudes over time to assess if the

implementation of the consumer’s choice seems to have made any differences in attitudes to similar

policy in elder care, health care and schools. Privatization is here used as an indicator of the ongoing

restructuring of the welfare service sector.

As above, OLS regressions are used for the purpose of checking whether the bivariate results still exist

when control variables are added. A vital variable to add is left-right orientation since privatization of

welfare is a highly ideological issue in Sweden (Bendz 2011). Also, educational level (where those

with higher education is generally more positive) and age (younger more positive than older) are

included as well as opinion about the choice reform (positive opinions on the choice reform in primary

health care and privatization in general is likely related). The attitudes to privatization are, as

explained in the above section, put together in an additive index.

Before and after

In the question, respondents are asked to give their opinions about a number of suggestions or

statements that are present in the political debate in Sweden in terms of positive or negative. In the

table, only the proportion of those that are positive towards the suggestions is showed.

Table 8: Attitudes to suggestions about privatization of welfare services, 2007, 2008 and 2010.All

respondents (users of primary health care) Proportion of positive answers.

Year 2007 2008 2010 Health care 29 (29) 29 (27) 30 (30) Elderly care 25 (25) 26 (24) 26 (25) Independent schools

22 (21) 23 (22) 23 (22)

Comment: The statements in the survey question have the following formulations. Health care: Letting more of health care be provided by private actors. Elderly care: Letting private companies run elderly care. Independent schools: invest more in independent schools.The sum of respondents for health care for respective year is 3242, 3065, 3080. Elderly care 3248,3066,3091. Independent schools 3228, 3079,3043.

The attitudes to the suggestions of privatisation of welfare service have hardly changed at all during

the years included in this analysis, for any of the three areas. Thus, the conclusion is that introducing

consumer’s choice in primary health care does not seem to have any consequences for the general

attitudes to related welfare policy, at least not over time. In an analysis of attitudes to privatisation in

21

Sweden over a longer time period, Nilsson (2007) concludes that the support for privatization in the

health care sector have increased since the middle of the 1990’s to 2006. Although this trend seem to

have stagnated during the last years according to the table above, the small increase in the proportion

that are positive towards privatization of health care in 2010 might be a part of this long term trend

rather than the implementation of consumer’s choice.


To save some space, the results for all three items are also here gathered in one table, only showing the

share of positive respondents.

Table 9: Attitudes to suggestions about privatization of welfare services by exit options in primary

health care, 2010. Proportion of positive answers.

None or limited exit options

Medium exit options Extensive exit options

Health care 28 25 32 Elderly care 23 17 28 Independent schools 20 23 23 Comment: The statements in the survey question have the following formulations. Health care: Letting more of health care be provided by private actors. Elderly care: Letting private companies run elderly care. Independent schools: invest more in independent schools. The groups of exit options are categorized based on the number and vicinity of primary health care centres in the local communities.The sum of answers is about 718 in group 1, about 255 in group 2 and about 2300 in group 3.

The results show that residents in local communities with good exit options, are more positive towards

letting health care be provided by private actors than those living in local communities with no or

limited exit options. Also the differences between exit-groups for the attitudes towards letting private

companies run elderly care shows the same pattern. The results concerning independent schools do not

show any significant differences between groups.

To check these results, we again take a look at the corresponding results from 2007 and 2008. For

health care, results from 2007 and 2008 show a similar pattern (although not significant for 2008).

Compared to 2007, the differences between the groups are a bit more distinct in 2010, where the share

that is positive in high exit option communities have increased. For elderly care, the pattern we see in

the table above is about the same in 2007 and 2008.

The tentative conclusion is that differences between the groups seem to have more to do with other

factors than with positive experiences from exit options in primary health care. A look at the

regression analysis confirms this conclusion: ideological orientation as well as age and opinion about

health care choice reform contributes to explain variation in privatization opinions, but not exit options.

22

Table 10: The impact of exit options on attitudes towards privatization of welfare services, with

control variables. (Unstandardised OLS estimates).

Variable B

None or limited exit options .11

extensive exit options -.45

Left-wing 1,8***

Right-wing --2,1***


Educational level .05

Age -.03***

Constant −65,139


p< 0,01 *** p < 0,05 ** p <0,1 * Comment: exit options is a dummy variable, where medium group is used as a base category. Left-right orientation is a dummy variable with neither left nor right as a base category. Opinion of choice reform is a binary variable (like/dislike). Age is measured as year of birth. Educational level is a binary variable with high/low education. Privatization is an index consisting of attitudes to privatization of health care, elder care and independent schools.

Active choice

Also in the table below, the share of positive respondents are presented for each item.

Table 11: Attitudes to suggestions about privatization of welfare services by activity, 2010. Share of

positive to the suggestions.

Active Not active Health care 31 25 Elderly care 26 24 Independent schools 23 21 Comment: The statements in the survey question have the following formulations. Health care: Letting more of health care be provided by private actors. Elderly care: Letting private companies run elderly care. Independent schools: invest more in independent schools. The question used for groups of active choice is: Which health care centre did you choose the first time you had the opportunity to choose? The alternative “made no active choice” is compared to the merged alternatives “chose the health care centre that was suggested” and “chose another health care centre than suggested”. N for the active group is about 2426, for the not active group about 450.

As regards attitudes towards privatizing more of the health care sector, the results in the table show

that the active choosers are more positive than those not active. For the other items, there is no

difference between groups.

23

Table 12: The impact of active choice on attitudes towards privatization of welfare services, with

control variables. (Unstandardised OLS estimates).

Variable B

active choice -.06

Left-oriented 1,7***

Right-oriented --2,3***

Opinion of choice reform -1,0***

Educational level -.16

Age -.03***

Constant 64,670


p< 0,01 *** p < 0,05 ** p <0,1 * Comment: Active choice is a binary variable (active/not active). Left-right orientation is a dummy variable with neither left nor right as a base category. Opinion of choice reform is a binary variable (like/dislike). Age is measured as year of birth. Educational level is a binary variable with high/low education. Privatization is an index consisting of attitudes to privatization of health care, elder care and independent schools.

The regression analysis show the same pattern as for exit groups above, empowerment in terms of

choosing actively do not have a significant effect for opinions about privatization when controlling for

other variables. Left-right orientation show a significant effect, as do age and opinion about choice

reform.

Using Exit Options

How do the attitudes to the welfare service policy look for those who have chosen to use the exit

opportunities in the primary health care system?

Table13: Attitudes to suggestions about privatization of welfare services by exit, 2010. Proportion of

positive answers.

Not exit Exit Health care 29 37 Elderly care 25 32 Independent schools 22 28 Comment: The statements in the survey question have the following formulations. Health care: Letting more of health care be provided by private actors. Elderly care: Letting private companies run elderly care. Independent schools: invest more in independent schools. The question used to categorize exit groups is: Did you during the last year choose a new health care centre? No/Yes, once/Yes, more than once. The two “yes”-alternatives are merged in the table. N for not -exit-group is about 2659, for exit-group about 460.

As is seen in the table, there is a distinct difference between the groups on all three items, but

especially regarding the privatization of health care. Those who have experience from using exit

opportunities are clearly more positive towards privatization in other areas. Thus, it seems like the

24

experience of exit options contributes to a positive attitude towards general welfare service policy.

How does this result hold when controlling for other factors?

Table 14: The impact of exit on attitudes towards privatization of welfare services, with control

variables. (Unstandardised OLS estimates).

Variable B

used exit option -.15

Left-oriented 1,8***

Right-oriented --2,2***

Opinion of choice reform -,98***

Educational level -.13

Age -.03***

Constant 67,131


p< 0,01 *** p < 0,05 ** p <0,1 * Comment: Using exit options is a binary variable (yes/no). Left-right orientation is a dummy variable with neither left nor right as a base category. Opinion of choice reform is a binary variable (like/dislike). Age is measured as year of birth. Educational level is a binary variable with high/low education. Privatization is an index consisting of attitudes to privatization of health care, elder care and independent schools.

Again, the regression analysis show that the above tendencies do not persist when including other

variables. All control variables except for education have a significant effect on privatization opinion.

In this case, it is of course natural that there is a difference between users and people in general: only

users of primary health care uses the opportunity to exit from their first choice of health care centre.

Interestingly, an analysis including only users of primary health care show a significant result (-.46**)

for the exit-variable. This means that among users of primary health care, having used the opportunity

to switch health care centre have a positive effect on attitudes to privatization in general.

Conclusions

The main conclusion from the analyses in this paper is that direct experience from empowerment in

primary health care service does not have any effects on contentment with the service or opinions

about the direction of the welfare state restructuring. This implicates that policy design do not, in this

case, have consequences for public opinion. In this section, I will discuss the implications of this result

along with some possible explanations and suggestions for further research.

First of all, there are some exceptions from the main conclusion. There is a convergence of attitudes

between those akin to pursue active choices concerning welfare services and the degree of

contentment. However, the causal relation can go in either direction and we should therefore be

25

careful not to draw too strong inferences on this possible exception to the general rule. But still, if the

direct experience of empowerment in terms of active participation in the program generates more

happiness with public service, then active participation might be a factor contributing to legitimacy for

the public sector. Also, active participation is a prerequisite for exit-mechanisms to work: if citizens

do not make active choices of service provider, then they will hardly be able to show the decision-

makers their opinion by either staying with an alternative or leave it.

The other significant result found was that among users of primary health care, there is an effect of

experience of exit on opinions of privatisation. Exit is a rather powerful way for citizens to make their

voice heard between elections and because of that a democratic tool in order to gain influence on

politics. If the mechanism works properly, citizens who are discontent with the welfare service

provided will exit and choose another alternative, thereby signalling their preferences to the politicians.

The amount of people who have used exit is this far rather small, since consumer’s choice in primary

health care is still new. It is quite safe to assume that this number will increase over time, not

necessarily only because people are discontent with their primary care but since people move or

change other life circumstances which might affect their choice of health care centre. It would thus be

interesting to re-make the analyses when there are a greater number of people to analyse.

An argument for implementing consumer’s choice is to give welfare users influence over the service,

foremost by freedom of choice and exit. For exit to be possible citizens must be willing to participate

in the system (being active) and there must be enough realistic exit options to choose from. As the

results in this paper show, neither of these factors have in itself effects on welfare opinion as measured

here. But since they are necessary conditions for the actual action of exiting, they are still important

for the functioning of democracy. An interesting question to elaborate on would be if those who have

experience from active participation in one program were more inclined to participate in other

programs. Since those who are positive towards privatization of welfare services tend to be more

active, positive experiences from a consumer’s choice model might spill over into more active citizens.

If tipping the power balance towards the citizens in one welfare service would have generated positive

responses also in other areas, this might have created a policy feedback mechanism that contribute to

reinforce the general policy change of the Swedish welfare service sector as described in the paper,

making the restructuring hard to reverse since the policy itself generates public support (c f Campbell

2003). The results from this study show that this kind of effect is unlikely in this case, at least as a

consequence of one reform in one policy area. An interesting question that could not be answered with

the presently available empirical material is what would happen if citizens got experience from

empowerment in several welfare service areas: would this have a stronger effect on opinions of the

26

general restructuring policy?

An argument in the paper, following research from for example Soss (1999) and Soss & Schramm

(2007), is that welfare state policy is a most likely-case for trying policy feedback-effects and also,

that the case that is analysed in this paper is particularly likely to generate effects since it is both

visible and proximate to the citizens. Also, it might be argued that Sweden as a country is an

especially interesting case because of it’s traditionally very extensive public sector that almost every

citizen meets frequently during their lifetime, which also means that the ongoing restructuring of the

welfare service sector have tangible consequences for the citizens. So, how come that the results in

this paper show very few effects? To conclude this section, I will briefly discuss some possible

explanations for this and also suggest some ways forward.

First, it might be the case that the implementation of consumer’s choice in primary health care is not

significant enough to create effects on public opinion: high visibility and proximity is not enough. But

it might also be the case that I’m barking up the wrong tree when it comes to where the effects should

be found, that there in fact are effects on public opinion and/or behaviour in other ways than

contentment with service and attitudes to privatization.1

Another explanation for the results is that people do not transfer direct experiences of empowerment

into opinions, either in general or just in this particular case. Is empowerment a mechanism that is

strong enough to create a link between welfare state experiences and public opinion? Since this have

been tested and proven in previous research, it is likely that the zero result is due to this particular case,

not to the theory in general. A related issue to be mentioned here is the possibility that the assumption

that direct experiences of empowerment have a stronger effect on public opinion than institutionalised

empowerment in general, is not that fruitful. But it could also be argued that this assumption should be

tried in more cases and with other designs before it is discarded. After all, the significant result

discussed above concerning the effects of experiencing exit is interesting enough to be further

elaborated on. A suggestion for further research is to try the effects of experience of empowerment in

cases where the group of “exiters” are larger and also in other welfare service programs than health

care, as well as in other institutional contexts and countries. Of course, the results could also be

attributed to methodological weaknesses such as a too “blunt” instrument for measuring opinions of

how primary health care works (contentment is, as mentioned above, not ideal), the use of statistical

technique or the fact that there are quite few respondents in some groups.

Consumer’s choice in primary health care is only one reform of many that puts new demands on the 1 During the process, I have analysed effects on for example trust (following previous research, e g Kumlin

27

Swedish citizens and contributes to change the character of the welfare state. The general research

question about the policy feedback effects of empowerment on public opinion could be more fully

answered if more aspects of the changes in the Swedish welfare sector were included. Also, it would

be interesting to extend the analysis to include more dependent variables on different levels. In

previous research, policy feedback effects are found on a very broad range of possible human

reactions to policy. To further develop the research area, it would be interesting to classify different

effects according to their distance from the policy, from policy-specific to generalised opinions on

how well government functions. This also raises questions such as how “far” in time and space from a

policy it is interesting and relevant to measure effects. In this paper, effects are measured quite close in

time from the policy change. This might for example mean that the public opinion reactions to the

policy in focus in this paper will change over time. The analysis will hopefully be more elaborated and

developed in this direction further on.

As mentioned in the introduction, the general idea that motivates this paper is that the changing

character of the welfare state may have implications for the relationship between state and individual.

With empowering comes responsibility. With the restructuring of welfare services, the individual

citizen gets more responsible for the quality and content of his or her own welfare than in the

traditional Social Democratic welfare model. What does this mean for how the citizen views his or her

relationship to the government? In further research, this question could be elaborated by extending the

analysis in the paper to include not only opinions and attitudes on specific welfare policy, but also on

how the relationship between individual and government is perceived by people in general and by

those who have direct experiences from empowerment. A related question is if and how a change in

the relationship between state and individual would affect the character of the Social Democratic

Welfare State and the consequences for how this kind of regime would be viewed in a comparative

perspective.

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References

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