Welfare states and health care systems Lecture 2 Ana Rico

STEPS IN INDUCTIVE POLICY RESEARCH DESCRIPTION Definition of the WS Types of welfare states and health care systems - Which are the relevant policy instruments in each sector? Evolution trends - Do different types evolve differently (diverge) or similarly (converge)? ANALYSIS Causes = determinants - Economic (e.g. industrialization, GDP growth), social (e.g. Illness, poverty, social structure), and political (e.g. voting, government coalitions) Consequences = social, economic and political impact - Which impact upon poverty, health, unemployment? National/by social group Policy implications - Which policy instruments should be selected in each country and sector, given the national configuration of causes, and the evidence on their consequences?

THE WELFARE STATE (Esping-Andersen, 2000 & 2003) OUTLINE OF THE SESSION INTRODUCTION THE WELFARE STATE (Esping-Andersen, 2000 & 2003) 1. Definition and measurement 2. Types of WS in Europe: Policy instruments 3. Consequences/outcomes 4. Causes of the welfare state: origin and evolution NATIONAL HEALTH CARE SYSTEMS (Blake & Adolino, 2001) Types: Beveridge, Bismark, (Shemashsko), Residual/market-based 5. Evolution and policy instruments 6. Determinants 7. Policy implications

1. THE WS: Definition and measurement Role of the state in the protection against life risks: A big public insurance company (Social Security), which also owns, or contracts with, a service provision company/ies (eg the British NHS) It usually includes: - Cash benefits: old age, unemploym., sick leave, maternity pensions In-kind benefits or welfare services: HC, social care, education But when is protection against risks extensive enough for an state to be called welfare state?: Initially: only states with universal, free programmes (Briggs 1969) Later: most civil servants work in welfare (Therborn 1983, quoted by Esping-Andersen 2000) Nowadays: At least 3 nearly universal programmes Mahoney (2004) WS regimes: role of state/market/family in protection from risks

1. THE WS, POLITICS & MARKETS: Definition GOVERNANCE & POLITICS DEMOCRATIC GOVERNMENT & INSTITUTIONS INTEREST GROUPS THE MARKET Financial markets PUBLIC & SOCIAL INSURANCE THE WS PRIVATE FINANCERS: Banks, insurers, citizens Product markets PUBLIC WELFARE SERVICE PRODUCTION PRIVATE PROVIDERS: Hospitals, doctors, schools, nursing homes

1. THE WS: Definition and measurement Quantitative indicators: expenditure (per hab. or GDP), % employment Qualitative indicators: nature of entitlement (poverty, employment, citizenship), ´decommodification´ (= universal = benefits independent of employment or income), coverage (% population), generosity of benefits, number of programmes covered Types of WS: Different types of WS: depending on values/ranking in quantitative and qualitative dimensions Causes of WS Main theses nowadays: Different types of WS (HC systems) have different causes Different WS sectors (eg pensions, HC) can be of different types, and have different causes

1. & 2.: THE WS, Measurement & Types Conservatism ITA AUS GER BEL FRA FIN IRE JAP NZ NETH NOR USA CAN UK DNK SWE AUZ SWI Neo-liberalism Socialdemocracy Based on Hicks & Kenworthy 2003

2 & 1. TYPES OF WS: Types and policy instruments (THREE + 1) WORLDS OF W CAPITALISM? (Esping-Andersen 1999) PUBLIC EMPLOYMENT AS A OF TOTAL (% STATE PRODUCTION) HIGH LOW SCANDINAVIA UK Spain Italy SHI COUNTRIES Austria, Germany Belgium, Neth., Lux. Canada Portugal Greece CEE (2) USA, Australia, New Zealand Switzerland CEE (1) SOUTH-EU (1) PUBLIC SOCIAL EXPENDITURE AS % OF TOTAL (% PUBLIC INSURANCE) SOUTH-EU (2)

EGALITARIAN Outcomes REGRESSIVE 2 & 3. TYPES OF WS : Instruments and consequences UNIVERSAL Pure (unmixted) Socialdemocratic Pure Christian Democratic: Employees EGALITARIAN Outcomes REGRESSIVE - % Covered + Pure liberal: Private insurance for the non-poor Pure liberal: Public insurance for the poor Pure ChisDem: Non-employed Pure CD: Private insurance for employers RESIDUAL Based on Esping-Andersen, 1990

2 & 3. TYPES OF WS: Instruments and consequences I. THE SOCIAL DEMOCRATIC WORLD 1. Policy instruments Redistributive financing & benefits Universal access (citizenship) Public provision of services Expanded services, active labour mkt & gender-egalitarian policies 2. Policy (outputs &) outcomes Public expenditure: High (output) Income:  Poverty & class inequality Employment:  gender & class inequality Main beneficiary: poor citizens/residents working women II. THE CONSERVATIVE (CHRISTIAN DEMOCRATIC) WORLD 1. Policy instruments Proportional financing & benefits Profess. groups (employm.-based) Private (NFP) provision of services Cash transfers across life cycle 2. Policy (outputs &) outcomes Public expenditure: High (output) Income:  inequality of workers at risk Employment:  total levels of employment Main beneficiary: middle-class families III. THE LIBERAL WORLD 2. Policy (outputs &) outcomes Public expenditure: Low Income:  Extreme poverty,  inequality Employment:  total levels of employment Main beneficiary: PUB: poor/old citizens PRIV: the wealthy 1. Policy instruments Regressive financing & benefits PUB: Redistr. PRIV: regressive Means-tested (income) Private (FP) provision of services

THE 3 WORLDS OF WELFARE CAPITALISM = National configurations of: 2. TYPES OF WS THE 3 WORLDS OF WELFARE CAPITALISM = National configurations of: * Social structure: Distribution of power, income, rights, status across social groups  Political ideologies (or subcultures) * Partisanship (party/ies in government)  * WS Policy instruments  * Policy outcomes by social group (distributional consequences) The liberal world The conservative world The social demo-cratic world

4. CAUSES OF THE WS Initially, Esping-Andersen theory was actor-centred (political parties): Socialdemocratic parties in government (Scandinavian) Welfare state Social structure and national culture As a reaction to social determinism in early marxist theory: Social structure Policy Political party In the 2000s, his theory becomes action-centred (and multi-causal): - what matters is not whether SD present in government, but - how they played the political game: mobilization in the streets, coalition with ‘middle-class’ parties, success of their prior policies

4. CAUSES OF THE WS: Origin and evolution Christian & conservative parties, unions & voters Political competition: * Electoral campaigns * Policy campaigns Political mobilization Coalitions Dominant national subcultures Socialdemocratic parties, unions & voters Social structure Policy change Liberal parties, progressive (state) elites, social protest SOCIAL SOCIOPOL. POLITICAL POLICY Based on Esping-Andersen 2000 & 2003; Jenkings & Brents 1987; Skocpol 1987

4. CAUSES OF THE WS: Origin and evolution Catholic parties & unions Christ.democratic parties Nationalist parties Anti-democratic parties CONSERVATIVE SOCIALDEMOCRATIC LIBERAL Individual and collective : POLITICAL ACTORS The Church The Army Aristocracy Landowners Monarchists Nationalists Fascists Small owners Socialist intellectuals Socialist party elites Socialist tradeunionists Blue-collar industrial workers Very poor agricultural workers Middle-class agricultural workers (White-collar indust. & service workers) Socialdemocratic parties Class-based unions Agrarian/rural parties (Professional unions) Liberal elites Employers Financers Exporter landowners Liberal parties Bussiness associations Liberal professions (eg doctors) Professional associations Based in Esping-Andersen 1990 & 2003

4. CAUSES OF WS: Origin and evolution Action-centred arguments National culture is not given, but rather a consequence of politics The socialists were a main cause of the WS, even when not present in government (state actor)  still influential as a pressure (sociopolitical) group, via political mobilization When in government, coalitions with other actors critical to explain success in WS development CONCLUSIONS: Main theses National cultures and WSs result from political struggles among ideological subcultures represented by competing coalitions, by which one became predominant over (but didn’t eliminate) the others In each WS subsector, an specific combination of conservative, liberal and socialdemocratic policy instruments exist, which is the result of the varying success of different competing coalitions. Based in Esping-Andersen 1990 & 2003

4. CAUSES OF THE WS: Evolution The increasing interpenetration among the 3 worlds 1. A common conservative historical origin (=Ancient Regime, absolutism) Characterized by (church) charity for the poor + guild-type mutual funds for the employed + extensive welfare role of family (women) Which became predominant in countries with weak liberal & socialdemocratic subcultures: the ChrisDem reform path, SHI crowds-out most private market 2. A competing liberal reform path (emerging in 1900-30, back in 1980-90s) Initially oriented to undermine Conservatism: public system substitutes charity; and markets substitute mutual funds Initially wins the battle in Anglosaxon, then Scandinavian countries Later oriented to undermine socialism; + slowly penetrating rest of the world 3. A socialdemocratic reform path (emerging in 1900-30, dominant in 1945-75) Which aimed first at removing 1.: Unions (& then the state) take over charity And then competes with 2.: The state takes over the private market too Varying penetration across EU: dominant in Nordic, SouthEU, UK NHS, CEE. Based in Esping-Andersen 2003

THE US EXCEPTION In WS cash transfers, similar to conservative model (if less generous) In HC, liberal  very limited role of the state (less than 50% of pop.) 1930s: Succesful pro-poor WS (cash transfers) reform BUT failed health care reform  1. Success WS + 2. Failure HC * Europe: 1880-1920s pro-poor WS + HC 1960s-1970s: Succesful pro-workers pension reform, limited unemployment reform, and very limited (pro-poor & aged) health care reform  1. Partial success WS + 2. Limited success HC * Europe: 1945-70s  Universal or pro-workers WS & HC (but Switerland, pro-workers HC in 1999) 1993-4: Failed universal health care reform  Failure HC * Europe: 1970s-90s  Further expansion of WS: From pro-workers to universal in CD WS New programmes (eg social care) in SD WS

Source: McKee, 2003

5. NATIONAL HEALTH SYSTEMS: Evolution & instr. HC POLICIES Mutual Aid Society Legislation Social Health Insurance National Health System HC SYSTEMS NHS Britain Sweden Denmark Italy Spain 1793 +, 1850 * 1891 +$, 1910 *$ 1892 $ * 1886 + $ * # 1859 $ # 1911 % [1919 %] 1931 % 1946 [1919 %] [1919 %] 1944 & 1942 % 1967 & @H 1946 NHS, @H, €H 1533 @H 1958 R 1969 € 1974 @PC 1946 && [1948 NHS] 1971 && NHS 1978 NHS @H € R 1986 NHS @PC SHI The Netherlands France Germany Belgium Austria 1852 $ + * 1898 # 1849 $ 1898 * [1919] 1943 + $ [1928 %] 1930 % 1945 & 1883 % 1944 & 1888 + $ # 1939 * 1798 @H 1958 €H SYMBOLS [failed reforms] Regulation of mutual funds + Special interest rates $ Government subsidies * Regulation of activities # Political controls Social Health Insurance % Compulsory, low-income workers & Compulsory for all salaried workers National Health Service NHS National Health Service && Universal @H Gov. ownership of hospitals @PC Gov ownership of PC € Full-time salaries (Hosp, PC) R Restrictions on private practice Based on Immergut E (1991): Medical markets and professional power: The economic and political logic of government health programmes, Working Paper 1991/24, Center for Advanced Studies in the Social Sciences, Juan March Institute, Madrid, Spain.

6. DETERMINANTS OF NHI REFORM Cultural explanations National culture (stable): Liberalism/individualism in Anglosaxon countries = “a distrust of government solutions to societal problems” Economic explanations (Convergence th): omitted, controlled by design: Does not explain differences among developed countries + US exception Institutional explanations A. Executive dominance: “Parliamentary systems feature stronger party discipline..., and greater centralization of legislative authority in the cabinet” B. Federalism C. Corporatism (as an indicator of interest groups’ formal political power) Political explanations (political actors and political action) Strong left political parties in government Public opinion: omitted from the analysis (see pp. 689-690) Interest groups: omitted, “the uneven success of IGs in blocking NHI points to the need to model the nature of IGs group politics” Political leadership, strategy, policy model: ommitted (see pp.702-3) From here on: Based on Blake & Adolino 2001

6. DETERMINANTS OF NHI REFORM: QCA measurement CONFIGURATIONS COUNTRIES Success NHI Failure NHS 5 factors +: SUELC 4 factors +: SuELC SUeLC SUElC Sweden, Norway Austria Denmark, Finland Luxemburg 2 1 3 factors +: sUELc SUeLc SUElc SUelC SueLC United Kingdom, New Zealand Iceland France Japan Belgium, Germany, Netherlands 3 2 factors +: SUelc sUElc SuELc sueLC Italy Ireland Australia, Canada Switzerland? 1-0 factors +: suelC suelc USA Supportive culture Unitary Executive dominance Left rule Corporatism

6. DETERMINANTS OF NHI REFORM: Analysis In the most generous WS, all 5 causes present: NOR, SWE Given a supportive culture, a left party, and a corporatist pattern of IGs intermediation, NHI enacted even if unfavourable political institutions AUS, DEN, FIN, BEL, GER, NETH 3. Unitary states with supportive cultures, enacted NHI even if rest of conditions unfavourable ICE, FRA, ITA, JAP 4. Anglosaxon countries with a dominant executive and left parties enacted NHI in spite of rest of factors unfavourable UK, IRE, CAN, AUSL, NZ 5. Causes of American excepcionalism: “The USA [is] the only country with unfavourable conditions in all 5 vars.” MAIN CONCLUSION: “To date, the absence of favourable [(political) institutions] has only been overcome by the simoultaneous presence of all three other supportive factors (culture, labour party, corporatism)”

7. POLICY IMPLICATIONS FOR THE USA (pp. 702-3) A. Reform political institutions (institutionalists) Unlikely, rules of constitutional revision very tough  OK for Executive dominance and Fedralism, but what about party discipline (part of E) or corporatism (C)?? NOTE: C defined as an institution, but in the discussion treated as a sociopolitical actor (Unions) B. Mobilize political support (action-centred) Need for the (1) Democratic party to overcome internal divides: progressive statists (similar to SD) mixed with liberals/conservatives  NOTE Amenta (2004) on North/South divisions within D party Need to develop strategies for (2) influencing public opinion, so that a supportive culture can develop; (3) mobilizing sociopolitical actors (e.g. citizen associations, social movements) which could play the role of unions  NOTE Briggs (1961) on USA 1935 SS Act and UK 1945 NHS