States Facing Interests: Struggles Over Health Care Policy in Advanced, Industrial Democracies

Abstract

Given alarming fiscal imperatives, states and interests in all advanced industrial democracies have struggled over health care policy. I explore the interface between state autonomy in health care policy and the political mobilization of provider interests, especially physicians. Evidence from Germany, Japan, Canada, and Great Britain suggests that, longitudinally, policy makers everywhere have tried to increase state autonomy in health care, and this has generally triumphed over even effectively mobilized providers. The countries that have most successfully restrained the growth of health care expenditures--while still providing ready access to relatively high-quality care--are those where states have most actively restrained both demand- and supply-side system interests in policy making. In each country, states have increasingly articulated their own greater capacities in health care policy, pushed to do so by the imperatives, especially fiscal, embedded in the policy domain.

Countervailing Agency: A Strategy of Principaled Regulation under Managed Competition

“…There are also some similarities between the strategy of countervailing agency and the notion of "countervailing power" that has been used to describe the forces shaping health policy in countries such as Germany (Stone 1980;Wilsford 1995). Countervailing power describes the balancing of various collective interests (physicians, sickness funds, employers, and government) in negotiations about practices ranging from fee schedules to financing arrangements for medical care.…”

Path Dependency and the Politics of Socialized Health Care

“…In his classic case study, Starr (1982) documents the role of the professionalization of medicine and the corporatization of insurance for the long-term development of US health care. Among the small-N comparisons (Dutton 2007;Immergut 1992;Okma et al 2010;Wilsford 1994;Wilsford 1995), Wilsford 1994 compares the development of health policy in France, Germany, the UK, and the United States. From this literature, one can find insightful histories of health policy for nearly all rich democracies.…”

“…Moreover, the prevalent homogenizing pressures of budget austerity, rising health care costs, population aging, and the medicalization of disease may combine to force countries to view or frame a high public share as unsustainable (Brady and Lee 2014;Kikuzawa, Olafsdottir, and Pescosolido 2008;Kittel and Obinger 2003;Pierson 2001). Indeed, rising costs and budget pressures have been a central concern for health care policy across rich democracies (Bevan, Helderman, and Wilsford2010;Marmor, Freeman, and Okma 2005;Reeves et al 2014;Wilsford 1995). 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."…”

“…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). Public health care is the first or second most expensive social policy in all rich democracies.…”

Reforming health care in Europe

“…Because the labour costs and tax rates needed to finance high levels of welfare spending make countries unattractive for economic investment, this continued rise in health spending constituted a 'fiscal imperative' for reform throughout the 1980s. 5 In the 1990s, it was exacerbated by further recession and the pressure placed on public budgets by governments keen to meet the Maastricht criteria for European It was in this context that governments set out to control the volume of resources consumed by the health sector. Their strategies for doing so included setting limits to whole budgets or to some of their component parts, and reducing employment and capital investment.…”