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Lecture 10 Summary Ana Rico, Associate Professor Department of Health Management and Health Economics [email protected] 2005 Health Politics: Types of WS and HC systems - Policy instruments - Impact: Social outcomes 2005 THE DEPENDENT VARIABLES: 1. THE WS, POLITICS & MARKETS: Definition GOVERNANCE & POLITICS INTEREST GROUPS 2005 DEMOCRATIC GOVERNMENT & INSTITUTIONS THE MARKET Financial markets PRIVATE FINANCERS: Banks, insurers, citizens PUBLIC & SOCIAL INSURANCE Product markets PRIVATE PROVIDERS: Hospitals, doctors, schools, nursing homes PUBLIC WELFARE SERVICE PRODUCTION THE WS 2 & 3. TYPES OF WS : Instruments and consequences + UNIVERSAL Pure liberal: Public insurance for the poor % Covered Based on Esping-Andersen, 1990 Pure Christian Democratic: Employees Outcomes Pure ChisDem: Non-employed RESIDUAL REGRESSIVE Pure liberal: Private insurance for the non-poor - EGALITARIAN 2005 Pure (unmixted) Socialdemocratic Pure CD: Private insurance for employers 2005 Source: McKee, 2003 CHANGES IN WELFARE POLICY WS expansion 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 Expansion of coverage, benefits and expenditure HC in CRISIS: Canada & US 2005 HC IN CRISIS? Canada, gov. approval 2005 2005 THE INDEPENDENT VARIABLES: - The political sysem - Context, actors, instits. , action Political, policy/sociopolitical and social systems SOCIAL CONTEXT CULTURE POLICY (SUB-) SYSTEM Social organiz. Sociopol. actors: * Ideologies * Ideas • IGs, Prof Ass., Unions • Citizens, Mass media • Political parties * Org.Struct. * Subcultures /pol.identities Social groups - Communities - Ethnia, gender - Social classes b THE POLITICAL SYSTEM a Policy change c Policy actors: •STATE-, POL. PARTs (IGs) CONSTITUTION HC SYSTE M Interactions: • Coalitions/competit. Institutions: • Const. (interorg.) • Organiz. Struct. • Leadership/strategy Outputs e d f INPUTS a. b. c. Outcomes POLITY Demands and supports Access to the political system Decision-making POLITICS POLICY d. Institutional change e. Impact of policy f. Distribution of costs and benefits OUTPUTS 2005 Associations • Churches • Firms • Policy MACRO: Political actors Citizens’ Associations 2005 MESO: Sociopol. actors The political game $ Political parties’ members Advisors and managers IGs - Bussiness - Insurance Profes. + providers’ Assoc. The socio-political context MICRO: Social actors The social context Patients’ Assoc. Patients’ ACTION-CENTERED THEORIES. 1.1. RQs REPRESENTATIVE DEMOCRACY State context RQ 2. Who influences policy? Policy context Social context RQ 4. How it governs? RQ 1. Who participates? (= seeks to influence policy) 2005 RQ 3. Who governs? “DIRECT” DEMOCRACY 2005 THE THEORIES: - Concepts - Hypotheses - Causal maps CONCEPTS (4): The state SOCIAL CONTEXT: The state as a ‘transmission belt’ of social pressures 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 2005 STATE-CENTRIC: The state as a unitary, independent actor with formal monopoly of (residual) power over policy-making SOCIAL & POLITICAL THEORIES 1950s/60s: SOCIAL CONTEXT SOCIAL PRESSURES L7 OLD INSTITUTIONALISM Formal political institutions L2, L4 SOCIAL ACTORS (IGs: dependent on social pressures) L5 POLITICAL ACTORS (STATE: independent of social pressures) L6 1990s: INSTITUTIONALISM (+state-society) SOCIOP. ACTORS (STATE-SOCIETY: interdependent) L9 2000s: ACTION THEORIES POWER-CENTRED THEORIES (interactions among collective actors & social structure) L7 NEW INSTITUTIONALISM (state institutions & state/PPs/IGs’ organization) L4, L9 RATIONAL CHOICE (interactions among individuals L7, L9 ACTOR-CENTERED INSTITUTIONALISM (interactions among institutions & elites) 2005 1970s/1980s: ACTORCENTRED L3 CAUSAL MAPS Social context & social actors theories Proposals of politically active groups 2005 Socioeconomic & cultural changes Changing class structure & new social needs Government action/Policy change State-centered theories State formation (bureaucratization, democratization Changing group and social needs How state organizations & parties operate Government action/Policy change What politically active groups propose Source: Orloff & Skocpol, 1984 CAUSES OF THE WS Social structure Coalition formation & Political competition * Electoral campaigns * Policy campaigns Socialdemocratic parties, unions & voters Liberal parties, progressive (state) elites, social protest SOCIAL 2005 Dominant national subcultures Christian & conservative parties, insurers, unions & voters SOCIOPOL. POLITICAL Based on Esping-Andersen 2000 & 2003; Jenkings & Brents 1987; Skocpol 1987 Policy change POLICY 2005 THE THEORIES (2): - Old and new debates SOCIAL vs. POLITICAL THEORIES “FATE” POLITICAL ACTORS (as representatives) independent of social groups SOCIAL CONTEXT Convergence theory Structural theories: capitalist/working class strength depends on distribution of ownership Cultural theories: INTEREST GROUPS (as delegates of social groups dependent on mandate) 2005 SOCIOPOLIT. ACTORS CHOICE interindependent national (anti- or statist) cultures inherited from history Bussiness associations & Unions Professional associations Contextual theories: Policy experts unusual conjunctures, policy windows Citizens´ preferences (= PO) Mass media Social movements CHANCE ACTORS & ACTION ACROSS THEORIES POWER ACTION ACTOR-CENTRED THEORIES (statecentric/state-society) Public interest (officials’ autonom. prefs./socioP infl.) State/SocioP capacity: inst + fin + know + CA res. Autonomous/ INSTITUTIONAL THEORIES Institutional norms & values Formal institutions Induced – ‘socialized’ RATIONAL CHOICE Game theory Private (self-) Interests Financial Resources Strategic ACTOR-CENTRED Ideas, interests & INSTITUTIONALISM institutions Instit. (+ fin & know) resources Strategic/ Induced POWER-CENTRED THEORIES Fin + know + instit + org. + CA resources Strategic/ Dependent on socioP infl. Resources (ideas), interests & ideologies Dependent on socioP influen. 2005 PREFERENCES ACTION-CENTERED THEORIES Positions in the main debate on causation in policy sciences: Interaction models Rational models Power-centred theories • Social groups • Power resources • Collective action • Coalitions Institutionalism • Organizations • Rules & norms • Expectations • Formal power 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... 2005 Rational choice • Individuals • Interests • Resources $ • Competition Incremental models TOWARDS TWO MAIN THEORIES? ACTOR-CENTRED INSTITUTIONALISM 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 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 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 2005 FROM (EC.) ACTION THEORIES: CAUSES OF POLICY CHANGE: Operationalization in WS/HC research Access Conjunctural factors: ec crisis, wars Socioeconomic structure: • Ownership, income • Education, knowledge • Social capital (status, support) • Sociopolitical structure: • Cleavages and political identities Values: Culture and subcultures • CONTEXT • Interest groups Profesional assocs. Poilitical parties State authorities Citizens: PO/SM Mass media Preferences Resources Distrib. of formal pol. power: electoral law, constitution, federalism, corporatism Contracts and org. structures Norms of behaviour Sanctions/incentives POLITICS: Strategies, Interactions POLITICAL ACTORS INSTITUTIONS Individual and collective - Formal and informal POLICY Adapted from Walt and Wilson 1994 Entitlements & rights Regulation of power, ownership, behaviour, contracts) Redistribution: Financing & RA Production of goods & services 2005 & participation Policy strategies Coalition-building Competition and cooperat. Changing resources Learning 2005 EVIDENCE: DETERMINANTS OF WS EXPANSION EVIDENCE Actor-centred institutionalist theory: HUBER et al 1993 (cont.) First incorporation of political institutions (‘constitutional structure’) Strength of federalism: low, medium, high Strength of bicameralism: low, medium, high Existence of presidentialism: yes, no Electoral system: Majoritarian, proportional modified, proportional Popular referendum: yes, no Left corporatism: degree (Openess of voting regulation: estimated via voter turnout) First disaggregation of the DV: The outcome we should study is not pro-WS or anti-WS but but rather the type of welfare policies: eg. Expenditure in Social Security benefits (total) Expenditure in transfer payments (cash transfers; excludes health care) Government revenue (indicator of state capacity state ownership) Entitlements: who are the beneficiaries, on which basis (income, employment, citizenship) Decommodification index (L1) Benefits equality (vs. Benefits proportional) REDISTRIBUTION 2005 EVIDENCE Actor-centred institutionalist theory: HUBER et al 1993 (cont.) 1. Socioeconomic context (as control variables) Aged, unemployed, economic growth, price & profits level 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 2005 2. Actors (1): Partisanship theory EVIDENCE Actor-centred institutionalist theory: HUBER et al 1993 (cont.) 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 2005 ACTION-C. THEORIES. 4. Evidence 1. Interactions among IVs or need to split into two (recodification) 1. Social protest (* social groups): Mobilization of lower classes: + WS Mobilization of upper classes: - WS Mobilization aparently no signficant effects on WS Need to model the interaction= No. Mobilized * Predominant upper (0) / lower (1) classes Or split the varible No. mobilized lower classes/Idem upper 2005 2. Correlations between Ivs (multicollineality): need to ommitt some 1. Ec. development, old age and left vote: Direct or indirect effects of aging? 2. Openess of the economy, left & ChD vote, corporatism, WS expenditure Aging WS expansion Left vote ACTION-CENTRED THEORIES. 4. Evidence A. Power-centred theory: Hichs & Mishra (cont.) : RESOURCES ANTI-WELFARE Central government Left & (ChD) center parties Right parties Interest organization Organized pro-W group activism Organized a-W group activ. Political mobilization Social protest (lower classes) Direct action (upper classes) Voting mobilization Newly mobilized voters Low voter turnout Territ. centralization Unitary countries Federal/devolved countries Statutory access of Igs YES: Left corporatism NO: Pluralism Financial resources High profit rates, inflation (?) Low profit rates, deflation State fiscal & fin. capacity High revenue as % of GDP Low revenue as % GDP State involvmnt as producer High public as % tot employment Low % public employment Policy legacy-social learning–national culture High status civil service, collectivism, equity Corrupted bureaucracies, individualism, freedom Political-CA resources Institutional resources 2005 PRO-WELFARE 2005 THE FUTURE: THE BATTLE FOR PUBLIC OPINION IN HEALTH POLITICS 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 WHY IS RELEVANT? (2) In health care: critical for electoral success & democratic legitimacy intense preferences but high asymmetric information In health care reform: Jacobs 1992: undivided and unambiguous PO reinforces state autonomy as it counterbalances IG pressures (UK 1945 vs US 1965); Navarro 1989/Quadagno 2004: powerful IGs in the USA (AMA 1920s1960s; 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 2005 WHY IS RELEVANT? (3) 2. As a PROXY of PROCESS Access, Pathways, Management Information, Trust, Shared decision-making 3. AS AN OUTCOME of HC (reform) Equity, financing and distributive justice Satisfaction, quality of life and productive efficiency NOTE: Citizens’ disatisfaction, AND perceptions of process & equity problems are indicators of bad performance of public HC Perceived performance constitutes the most important cause=input of HC reform for policy-feedback theory 2005 DETERMINANTS Interests: social structure vs. choice Values CULTURE As core beliefs: solidarity, equality, safety Varying by ideological subcultures: Social-democracy: universality, solidarity Political liberalim: equality of opportunity Progressive conservatism: responsibility, safety Peers, Media, Elites (politicians, doctors, industry) POLITICS Performance POLICY experienced and perceived egocentric and sociotropic Based on: Maioni A (2002): Is public health care politically sustainable?, Presentation for the Canadian Fundation for Humanities and Social Sciences; and 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 HC Woman .15* .09* Age .004 .02* Unemployment .36* .03 Egalitarian ideology .76* .37* Unemployment .17* .12* National ideology .29* .03 INDIVIDUAL LEVEL NATIONAL LEVEL 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 PUBLIC UNEM. POLICY PO: SUMMARY & CONCLUSIONS 2005 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 decisionmaking 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 WHO PARTICIPATES? At the aggregate level, the decision to engage in collective action depends on 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 2005 1. the intensity of political conflict across social cleaveages (class/income, religion/values, community/ethnia), ideologies and political issues (social structuralism) and ...