Healthcare

This chapter provides insights into one of modern society’s most crucial arenas. Compared with other social policy fields, health policy concentrates less on benefits in cash and more on services (see also Chapter 9). Service provision is of great importance when analysing healthcare. Furthermore, governance and regulation in healthcare demonstrate major conflicts due to the presence of influential interest groups. While healthcare expenditure, financing, and provision can be assessed on the basis of quantitative data, analysing regulation and governance requires a combination of qualitative and quantitative data and methods. In this chapter, we first discuss core concepts of comparing healthcare policy and politics. We then assess developments in expenditure and healthcare provision. Finally, we discuss regulations in different healthcare systems and how regulation is related to patients’ access to healthcare. We provide information for 32 Organisation for Economic Co-operation and Development (OECD) countries and reveal which countries are more successful in controlling costs as well as in translating monetary inputs into healthcare provision. Comparative studies of health policy and politics can be distinguished by whether they focus on health policy actors and reform or on healthcare systems. The first group of studies concentrates on the role of political institutions, health policy decision-makers, and organized interests in health reform. The second group of studies analyses and compares institutions and characteristics of healthcare systems. In the following section, we discuss some of the most influential concepts in both clusters of writing. Immergut’s (1992) comparison of France, Sweden, and Switzerland still sets the standard for studying the role of political institutions and actors in healthcare reform. She focused on the veto potential of interest groups in different settings and showed that veto opportunities arise out of the specific features of political institutions. Her study suggests that the impact of physicians’ organizations on health policy may have been much less decisive than was generally believed until the late 1980s. Immergut concluded that veto points in the political system are of greater importance than veto groups within society. Similarly, but with more emphasis on process tracing, Hacker (1998) analysed how political institutions systematically channel the way in which ideas and interests shape political debates and decision-making. His study of the historical sequence and timing of health policy change in Britain, Canada, and the United States clearly supports the policy importance of historical legacies and therefore the path-dependence thesis. A country’s health policy path, he contended, is significantly influenced, first, by whether a sizable part of the population is enrolled in private plans before national health insurance is on the political agenda; second, by whether public health plans be targeted at residual populations from the outset; and third, by whether medical care be a substantial industry before the universal health insurance is politically salient. The United States fails on all three conditions, a fact that Hacker used to explain the much higher barriers to universal healthcare. Other concepts have concentrated on governance and regulation. Tuohy (1999) provides the most theoretical approach to models of governance. She proposed that the dominant model of accountability in healthcare changed from agency to contract models and may currently shift toward complex networks. In the older, trust-based, principal-agent relationship, the state (the principal) delegated authority for the regulation and distribution of healthcare to the medical profession (the agent). As a result of better access to information, the medical profession dominated this model of governance until the end of the twentieth century. New information technologies, however, have provided governments with better information, reducing the information asymmetry between the state and the medical profession. Thus, a transformation from an agency to a contract model has taken place in many countries. In a contract model, the state’s role is to purchase rather than to simply finance healthcare. The medical profession’s loss of autonomy is due less to cost pressures than to the way in which the provision and verification of detailed medical information strengthens governments’ power. In his concept of ‘the health care state’, Moran (1999) classified healthcare systems according to three governing concepts: consumption, provision, and production. By consumption, Moran refers to patients’ basis of eligibility for access to healthcare and to financing mechanisms. The provision dimension encompasses the control of hospitals and doctors, and the production dimension encompasses mechanisms that regulate medical innovation. Based on these dimensions, Moran constructed four types of healthcare states: the ‘entrenched command-and-control state’ (Scandinavian countries, Great Britain); the ‘supply state’ (United States); the ‘corporatist state’ (Germany); and the ‘insecure command-and-control state’ (Greece, Portugal). ‘Supply states’ are dominated by provider interests in all three dimensions, and this domination of suppliers, not the operation of market principles, is the primary problem with American healthcare. In ‘command-and-control states,’ on the other hand, the state is distinctive in all three governing concepts. Although they provide universal healthcare in legal terms, Southern Europe’s ‘insecure command-and-control states’ lack the administrative capacities for guaranteeing universal coverage and equal access to care – principles that have characterized the Nordic countries and Great Britain for many decades. In ‘corporatist healthcare states,’ finally, public-law bodies and doctors’ associations are dominant. Wendt, Frisina, and Rothgang (2009) suggested a conceptual framework that simultaneously measures the role of the state in financing, service provision, and regulation compared with private and societal actors (see also Rothgang et al., 2010). Three ideal-type healthcare systems were identified: ‘state healthcare systems,’ in which the state is dominant in financing, provision, and regulation; ‘societal healthcare systems,’ in which societal actors such as social insurance funds are dominant in all three dimensions; and ‘private healthcare systems,’ in which all three dimensions fall under the auspices of private for-profit actors. Along with each category of ideal-type, six combinations of mixed types were identified for which state, societal, or private actors and institutions are dominant in two dimensions. Six additional combinations do not approach any of the three ideal-types. Comparative studies that apply this methodological framework or similar concepts may produce richer descriptive portraits. Germany, for instance, does not represent an ideal-type societal (or corporatist) model as suggested by Moran (2000)

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