Upload
gwendolyn-arnold
View
219
Download
1
Tags:
Embed Size (px)
Citation preview
2005
Health Politics:
Lecture 10
Summary
Ana Rico, Associate Professor
Department of Health Management and Health Economics
2005THE DEPENDENT VARIABLES:
Types of WS and HC systems- Policy instruments
- Impact: Social outcomes
2005
DEMOCRATIC GOVERNMENT &
INSTITUTIONS
PUBLIC & SOCIAL INSURANCE
PUBLIC WELFARE SERVICE
PRODUCTION
GOVERNANCE & POLITICS
THE MARKET
Financial markets
Product markets
INTEREST GROUPS
PRIVATE FINANCERS: Banks, insurers, citizens
PRIVATE PROVIDERS: Hospitals, doctors, schools, nursing homes
THE WS
1. THE WS, POLITICS & MARKETS: Definition
2005
EGALITARIAN Outcomes REGRESSIVE
-
% C
overe
d
+
2 & 3. TYPES OF WS : Instruments and consequences
Pure (unmixted) Socialdemocratic
UNIVERSAL
RESIDUAL
Pure liberal: Public insurance for the poor
Pure Christian Democratic: Employees
Pure ChisDem: Non-employed
Pure CD: Private insurance for employers
Pu
re liberal: P
rivate insurance
for the n
on-poor
Based on Esping-Andersen, 1990
2005
Source: McKee, 2003
2005
CHANGES IN WELFARE POLICY
WS expansion
Expansion of coverage, benefits and expenditure
WS retrenchment
Decrease in coverage, benefits and expenditure
WS resilience
Stable in coverage, benefits and expenditure. Resistant to change
WS re-structuring
Change in distribution of benefits & expenditure across social
groups
2005
HC in CRISIS: Canada & US
2005
HC IN CRISIS? Canada, gov. approval
2005
THE INDEPENDENT VARIABLES:- The political sysem
- Context, actors, instits. , action
2005
a. Demands and supportsb. Access to the political systemc. Decision-making
d. Institutional changee. Impact of policyf. Distribution of costs and benefits
Policy actors:•STATE-, POL. PARTs (IGs)
Policy change
INPUTS
Outcomes
THE POLITICAL SYSTEM
POLICY (SUB-) SYSTEM
a c
d e
b
OUTPUTS
Outputs
POLICYPOLITICSPOLITY
f
HC SYSTEM
Political, policy/sociopolitical and social systems SOCIAL CONTEXT
Institutions:• Const. (interorg.)• Organiz. Struct.
Interactions:• Coalitions/competit.• Leadership/strategy
Sociopol. actors:
• IGs, Prof Ass., Unions• Citizens, Mass media• Political parties
CONSTITUTION
CULTURE
* Org.Struct.
* Subcultures /pol.identities
* Ideologies * Ideas
Social organiz. • Associations • Churches• Firms
Social groups - Communities- Ethnia, gender- Social classes
2005
$
The social context
The political game
HC SYSTEM
The socio-political context
Policy
MACRO: Political actors
MESO: Sociopol. actors
MICRO:Social actors
Citizens’ Associations
Political parties’ members IGs
- Bussiness - Insurance
Profes. + providers’ Assoc.
Patients’ Assoc. Patients’
Advisors and managers
2005
ACTION-CENTERED THEORIES. 1.1. RQs
Social context
Policy context
State context
RQ 1. Who participates? (= seeks to influence policy)
RQ 2. Who influences policy?
REPRESENTATIVE DEMOCRACY “DIRECT” DEMOCRACY
RQ 3. Who governs?
RQ 4. How it governs?
2005THE THEORIES:- Concepts
- Hypotheses- Causal maps
2005
SOCIAL CONTEXT: The state as a ‘transmission belt’ of social pressures
STATE-CENTRIC: The state as a unitary, independent actor with formal monopoly of (residual) power over policy-making
STATE-SOCIETY: The state as a set of political representatives and policy experts with preferences and action partly independent, and partly determined by a wide range of social actors’ pressures
INSTITUTIONALIST: The state as a set of political institutions; or as a set of elites with preferences and actions mainly determined by institutions
ACTION: As a set of political organizations which respond to context, sociopolitical actors and institutions; and which compete and cooperate (=interact) to make policy
CONCEPTS (4): The state
2005
SOCIAL PRESSURES OLD INSTITUTIONALISM Formal political institutions
SOCIAL ACTORS (IGs: dependent on
social pressures)POLITICAL ACTORS (STATE: independent
of social pressures)
SOCIOP. ACTORS (STATE-SOCIETY: interdependent) NEW INSTITUTIONALISM
(state institutions & state/PPs/IGs’ organization)
POWER-CENTRED THEORIES (interactions among collective actors & social structure)
RATIONAL CHOICE (interactions among individuals
ACTOR-CENTERED INSTITUTIONALISM (interactions among institutions & elites)
1950s/60s: SOCIAL CONTEXT
1970s/1980s: ACTOR-CENTRED
1990s: INSTITUT-IONALISM (+state-society)
2000s: ACTION THEORIES
SOCIAL & POLITICAL THEORIES
L3
L5L2, L4
L6
L7
L9L4, L9
L7
L7, L9
2005
CAUSAL MAPS
Government action/Policy change
Source: Orloff & Skocpol, 1984
State formation (bureaucratization, democratization
Socioeconomic & cultural changes
Changing class structure & new social needs
Proposals of politically active groups
How state organizations & parties operate
Changing group and social needs
What politically active groups propose
Government action/Policy change
Social context & social actors theories
State-centered theories
2005
CAUSES OF THE WS
Based on Esping-Andersen 2000 & 2003; Jenkings & Brents 1987; Skocpol 1987
Policy change
Social structure
Christian & conservative parties, insurers, unions & voters
Socialdemocratic parties, unions & voters
Coalition formation & Political competition
* Electoral campaigns * Policy campaigns
Dominant national subcultures
Liberal parties, progressive (state) elites, social protest
SOCIAL POLITICAL POLICYSOCIOPOL.
2005
THE THEORIES (2):- Old and new debates
2005
SOCIAL vs. POLITICAL THEORIES
Bussiness associations & Unions
Professional associations
Policy experts
Citizens´ preferences (= PO)
Mass media
Social movements
““FATE”FATE”
SOCIAL CONTEXT
Convergence theory
Structural theories: capitalist/working class strength depends on distribution of ownership
Cultural theories: national (anti- or statist) cultures inherited from history
Contextual theories:
unusual conjunctures, policy windows
CHANCECHANCE
CHOICECHOICE
INTERESTGROUPS (as delegates of social groups dependent on mandate)
POLITICAL ACTORS (as representatives) independent of social groups
SOCIOPOLIT. ACTORS interindependent
2005
PREFERENCES POWER ACTION
ACTOR-CENTRED
THEORIES (state-
centric/state-society)
Public interest
(officials’ autonom.
prefs./socioP infl.)
State/SocioP
capacity: inst + fin
+ know + CA res.
Autonomous/
Dependent on
socioP influen.
INSTITUTIONAL
THEORIES
Institutional norms
& values
Formal institutions Induced –
‘socialized’
RATIONAL CHOICE
Game theory
Private (self-)
Interests
Financial
Resources
Strategic
ACTOR-CENTRED
INSTITUTIONALISM
Ideas, interests &
institutions
Instit. (+ fin &
know) resources
Strategic/
Induced
POWER-CENTRED
THEORIES
Resources
(ideas), interests
& ideologies
Fin + know +
instit + org. + CA
resources
Strategic/
Dependent
on socioP infl.
ACTORS & ACTION ACROSS THEORIES
2005
Positions in the main debate on causation in policy sciences:
From actor-centered (simple) to action-centered (complex):
From monocausal explanations: emphasys on one actor as key determinant
To multicausal models which: Compare the relative preferences & power resources of actors Analize the interactions between institutions, past policy and context Map actors’ changing choices and strategies Examine actors’ interactions in the political process...
Rational choice Power-centred theories• Individuals
• Interests• Resources $• Competition
• Social groups• Power resources• Collective action• Coalitions
Institutionalism• Organizations• Rules & norms• Expectations • Formal power
Rational models
Incremental models
Interaction models
ACTION-CENTERED THEORIES
2005TOWARDS TWO MAIN
THEORIES?
POWER-CENTRED TEORIES
FROM (EC.) ACTION THEORIES: Changing strategy & resources as key causes of
policy change
Actors as complex coalitions of political organizations and social groups steered by political leaders & enterpreneurs
FROM STRUCTURAL THEORIES:
Social power resources as the main actors’ characteristic
Politics as an unequal, oligopolistic game in which stakeholders have permanent advantage
Access and strength of stakechallengers &
weakest social groups explains policy change
Stakeholders must be divided
ACTOR-CENTRED INSTITUTIONALISM
FROM (EC.) ACTION THEORIES:
Choice & strategy as key causes of policy change
Political actors as individuals links with society reduced to basic resources ($, vote) + internal cohession assumed rather than investigated
Preferences as the main actors’ feature + formal institutional power resources
Politics as a balanced game: interests compete on equal terms, none has permanent advantage
FROM ACTOR-CENTRED THEORIES:
Dominant actors (with formal, institutional political power) explain policy change
2005CAUSES OF POLICY CHANGE:
Operationalization in WS/HC research
Adapted from Walt and Wilson 1994
Distrib. of formal pol. power: electoral law, constitution, federalism, corporatism Contracts and org. structures Norms of behaviour Sanctions/incentives
CONTEXT
INSTITUTIONS
POLITICS: Strategies, Interactions
Individual and collective
• Socioeconomic structure:• Ownership, income• Education, knowledge• Social capital (status, support)
• Sociopolitical structure:• Cleavages and political identities
• Values: Culture and subcultures
-
Access & participation Policy strategies Coalition-building Competition and cooperat. Changing resources Learning
POLICY Entitlements & rights Regulation of power, ownership, behaviour, contracts) Redistribution: Financing & RA Production of goods & services
Conjunctural factors: ec crisis, wars
Interest groups Profesional assocs. Poilitical parties State authorities Citizens: PO/SM Mass media
POLITICAL ACTORS
Preferences
ResourcesFormal and informal
2005EVIDENCE: DETERMINANTS OF
WS EXPANSION
2005
Actor-centred institutionalist theory: HUBER et al 1993 (cont.)
First incorporation of political institutions (‘constitutional structure’)
Strength of federalism: low, medium, high
Strength of bicameralism: low, medium, high
Existence of presidentialism: yes, no
Electoral system: Majoritarian, proportional modified, proportional
Popular referendum: yes, no
Left corporatism: degree
(Openess of voting regulation: estimated via voter turnout)
First disaggregation of the DV: The outcome we should study is not pro-WS or anti-WS but but rather the type of welfare policies: eg.
Expenditure in Social Security benefits (total)
Expenditure in transfer payments (cash transfers; excludes health care)
Government revenue (indicator of state capacity state ownership)
Entitlements: who are the beneficiaries, on which basis (income, employment, citizenship) Decommodification index (L1)
Benefits equality (vs. Benefits proportional) REDISTRIBUTION
EVIDENCE
2005
1. Socioeconomic context (as control variables)
Aged, unemployed, economic growth, price & profits level
2. Actors (1): Partisanship theory
Socialdemocratic government boost expenditure, universalism & public
provision of services + weak effects on cash transfers
Christian Democratic parties boost cash transfers proportional to income
3. Actors (2): Statist theory
Strong + effects of state fiscal capacity
Weaker effects of state employment capacity
4. Institutions: Statist/institutionalist theory
Inconsistent effects of government centralization and corporatism
Significant effects of constitutional structure (number of veto points)
5. Process and action
Strong + effects of political mobilization (voting) of the lower classes
But not of social protest
Actor-centred institutionalist theory: HUBER et al 1993 (cont.)
EVIDENCE
2005
General findings on causal mechanisms behind WS expansion A. Some factors have direct, clear effects:
Strength of Social & Christian Democracy (strong subcultures + parties)
Constitutional structure (institutional concentration of state power)
State fiscal capacity (financial power resources of the state)
B. Other factors have less direct effects, either contingent (on
conjuncture/country) and/or conditional (on interactions with other vars.)
Eg.: Federalism, social protest, economic context, state employment
capacity
C.Other factors are so correlated to each other that is difficult to know about
their independent effects on policy
Eg.: Aging and left vote; consensual democracy and corporatism
Actor-centred institutionalist theory: HUBER et al 1993 (cont.)
EVIDENCE
2005
1. Interactions among IVs or need to split into two (recodification) 1. Social protest (* social groups):
Mobilization of lower classes: + WS
Mobilization of upper classes: - WS
Mobilization aparently no signficant effects on WS
Need to model the interaction= No. Mobilized * Predominant upper (0) /
lower (1) classes
Or split the varible No. mobilized lower classes/Idem upper
2. Correlations between Ivs (multicollineality): need to ommitt some 1. Ec. development, old age and left vote:
Direct or indirect effects of aging?
2. Openess of the economy, left & ChD vote, corporatism, WS expenditure
Aging
Left vote
WS expansion
ACTION-C. THEORIES. 4. Evidence
2005
A. Power-centred theory: Hichs & Mishra (cont.) :
RESOURCES PRO-WELFARE ANTI-WELFARE
Political-CA resources Central government
Interest organization
Political mobilization
Voting mobilization
Left & (ChD) center parties
Organized pro-W group activism
Social protest (lower classes)
Newly mobilized voters
Right parties
Organized a-W group activ.
Direct action (upper classes)
Low voter turnout
Institutional resources Territ. centralization
Statutory access of Igs
Unitary countries
YES: Left corporatism
Federal/devolved countries
NO: Pluralism
Financial resourcesState fiscal & fin. capacity
State involvmnt as
producer
High profit rates, inflation (?)
High revenue as % of GDP
High public as % tot employment
Low profit rates, deflation
Low revenue as % GDP
Low % public employment
Policy legacy-social
learning–national culture
High status civil service,
collectivism, equity
Corrupted bureaucracies,
individualism, freedom
ACTION-CENTRED THEORIES. 4. Evidence
2005THE FUTURE: THE BATTLE FOR PUBLIC OPINION
IN HEALTH POLITICS
2005
WHY IS RELEVANT? (1)
Public opinion = citizens’s preferences and perceptions
1. AS AN INPUT in health care (HC) reform Citizens as voters (voice), users (exit) and tax-payers (loyalty) in
democracies
Main input in politicians’ utility functions
An independent determinant of policy?
The debate on manipulation: Schumpeter vs. Jacobs
A critical determinant of policy when... Well-established, non-ambivalent attitudes resulting from active
interpretation & discussion (political mobilization and civic
culture)
Democratic competition: divergent elites & messages
Very popular or impopular policies (issue salience)
Schumpeter JA (1950): Capitalism, Socialism and Democracy, NY: Harper. Jacobs (2001): Manipulators and manipulation: Public opinion in a representative democracy, Journal of Health Politics, Policy and Law, 26, 6, 1361-1373.
2005
In health care:
critical for electoral success & democratic legitimacy
intense preferences but high asymmetric information
In health care reform:
Jacobs 1992: undivided and unambiguous PO reinforces state autonomy
as it counterbalances IG pressures (UK 1945 vs US 1965);
Navarro 1989/Quadagno 2004: powerful IGs in the USA (AMA 1920s-
1960s; Insurers 1980s-2000s; both) invest substantial resources in
counter-reform PO campaigns (=Immergut 1992 on Switzerland)
Jacobs 2003: Harry & Louise against the Clintons: unmanipulated PO
requires competitive mass media + political mobilization (soc. mov.)
Briggs 2000 (/Hall 1993/Weir & Skocpol 1984) : Social scientists, unions
and policy enterpreneurs played a critical role in counterbalancing IGs
campaigns in Europe
WHY IS RELEVANT? (2)
2005
2. As a PROXY of PROCESS Access, Pathways, Management
Information, Trust, Shared decision-making
3. AS AN OUTCOME of HC (reform)
Equity, financing and distributive justice
Satisfaction, quality of life and productive efficiency
NOTE:
Citizens’ disatisfaction, AND perceptions of process & equity problems are indicators of bad performance of public HC
Perceived performance constitutes the most important cause=input of HC reform for policy-feedback theory
WHY IS RELEVANT? (3)
2005
Interests: social structure vs. choice
Values CULTURE As core beliefs: solidarity, equality, safety
Varying by ideological subcultures: Social-democracy: universality, solidarity
Political liberalim: equality of opportunity
Progressive conservatism: responsibility, safety
Peers, Media, Elites (politicians, doctors, industry) POLITICS
Performance POLICY experienced and perceived
egocentric and sociotropic
Based on: Maioni A (2002): Is public health care politically sustainable?, Presentation for the Canadian Fundation for Humanities and Social Sciences; and
DETERMINANTS
2005
RECENT TRENDS
Its role is expanding... In health policy: ideas, evidence, leadership
In health politics: conflict over resouces, deciding on rules and responsibilities, battle for public opinion
... Due to increased salience & more informed citizens
(Maioni, 2002; reference in previous slide)
Its shape is changing... Increased perception of crisis (finance, access, quality)
Satisfaction with medical care received high
Stable or expanding core values: HC as a social right
Media and industry more influential; doctors & peers less; government depends
More educated = autonomous citizens?
2005
DETERMINANTS OF SUPPORT FOR STATE INVOLVEMENT,
24 OECD countries, ISSP 1997
PUBLIC UNEM. POLICY PUBLIC HC
INDIVIDUAL LEVEL
Woman .15* .09*
Age .004 .02*
Unemployment .36* .03
Egalitarian ideology .76* .37*
NATIONAL LEVEL
Unemployment .17* .12*
National ideology .29* .03
Source: Blekesaune M and Quadagno J (2003): Public attitudes towards welfare state policies: A comparative analysis of 24 nations, European Sociological Review, 19, 5: 415-427.
2005
PO: SUMMARY & CONCLUSIONS
Public opinion (citizens’ preferences and perceptions)… Plays a critical role in democracy: responsiveness, accountability,
quality of democracy Is also useful as a HC input & outcome + to track process Sits at the centre of politicians’ utility functions, and is a critical
determinant of public policy (veto) Is increasingly the target of IGs public opinion campaigns Requires active political mobilization, information and shared decision-
making to become an effective, independent force Future challenges
Should the state invest in guaranteeing an independent, effective PO? How? Media anti-trust policy & citizens’ associations?
Should the state counterbalance IGs’ media campaigns? How? A substantial public investment in data, information and research on
PO (and professionals’ one!) is required Analysis of routine national series is a high priority
2005
At the aggregate level, the decision to engage in collective action depends on
1. the intensity of political conflict across social cleaveages (class/income, religion/values, community/ethnia), ideologies and political issues (social structuralism) and ...
2. the extent to which there are political elites/organizations who actively mobilize (and represent) their constituencies (power resources theories actor/action);
3. ... which in turns depends on the extent to which state policies grants equal political & social rights to under/priviledged groups (policy feedbacks)
4. the openess of democratic institutions to direct political participation (institutionalism), eg voting regulations, neocorporatism, popular legislative initiative, referendum
NOTE: Olson’s thesis are compatible with all the above
WHO PARTICIPATES?