Healthcare Systems in Comparative Perspective: Classification, Convergence, Institutions, Inequalities, and Five Missed Turns

Abstract

This essay reviews and evaluates recent comparative social science scholarship on healthcare systems. We focus on four of the strongest themes in current research: (1) the development of typologies of healthcare systems, (2) assessment of convergence among healthcare systems, (3) problematization of the shifting boundaries of healthcare systems, and (4) the relationship between healthcare systems and social inequalities. Our discussion seeks to highlight the central debates that animate current scholarship and identify unresolved questions and new opportunities for research. We also identify five currents in contemporary sociology that have not been incorporated as deeply as they might into research on healthcare systems. These five “missed turns” include an emphasis on social relations, culture, postnational theory, institutions, and causal mechanisms. We conclude by highlighting some key challenges for comparative research on healthcare systems.

Path Dependency and the Politics of Socialized Health Care

“…For instance, Huber and Stephens (2001: 76, 217) evaluate whether power resources theory predicts the public share of health spending similarly to other welfare effort outcomes. Further, scholars have developed comparative typologies of health care systems with parallels to the welfare state regime literature (Bambra 2005;Beckfield, Olafsdottir, and Sosnaud 2013;Moran 2000;Wendt 2009). Despite these contributions, there are still relatively few cross-national analyses of the public share of health spending.…”

“…As Hacker (2004: 698) explains, "rapid inflation of health spending was usually the largest and most immediate source of budgetary strain for countries facing up to the new fiscal order." These pressures should constrain high public share countries even more than low public share countries, partly because high public share countries approach the ceiling of 100 percent public financing, and, because health care is a larger share of government budgets in high public share countries (Beckfield, Olafsdottir, and Sosnaud 2013;Nixon 1999). Compared to low public share countries, high public share countries are more able to control costs because health care financing is more centralized and the state is relatively more powerful than private actors (Wendt 2015).…”

“…As an additional robustness check, we experimented with incorporating health care regimes in analyses available upon request (Beckfield, Olafsdottir, and Sosnaud 2013;Wendt 2009). Reestimating model 3, the analyses reveal that indicators for health care regimes do significantly influence the public share (e.g., adding a dummy for national health service; or dummies for "universal coverage-controlled access" and "low budget-restricted access" in reference to "health service provisionoriented" [Wendt 2009]).…”

“…We conceptualize the public share as one meaningful indicator of the "socialization" of health care, public investments in health and health care, and the extent to which the state covers health care costs. The public share reflects policy differences in the organization of health care (Maarse 2006), and is one, while certainly not the only, key manifestation of the underlying differences in institutional regimes (e.g., national health services vs. national insurance systems) (Beckfield, Olafsdottir, and Sosnaud 2013;Wendt 2009). The size of the public share influences health care costs, shapes the organization of insurance, and affects how costs and risks are distributed across the population (Anderson et al 2003;Jordan 2011;Laugesen and Glied 2011;Morgan and Campbell 2011;Reinhardt, Hussey, and Anderson 2004;Tuohy, Flood, and Stabile 2004;Wilkerson 2003;Wilsford 1995).…”

Health Insurance: Economic and Risk Aspects

“…Health care systems are often classified in many different ways depending on the types and numbers of factors researchers might find relevant to consider (Beckfield et al, 2013). A health system, however, is determined by the interaction of different actors, such as insurers, patients, and medical providers.…”