PUBLIC HEALTH POLICIES AND SOCIAL INEQUALITY
Also by Charles F Andrain CHILDREN AND CIVIC AWARENESS COMPARATIVE POLITICAL SYSTEMS: Policy Performance and Social Change CONTEMPORARY ANALYTICAL THEORY (editor with David E. Apter) FOUNDATIONS OF COMPARATIVE POLITICS POLITICAL CHANGE IN THE THIRD WORLD POLITICAL LIFE AND SOCIAL CHANGE POLITICAL PROTEST AND SOCIAL CHANGE: Analyzing Politics (with David E. Apter) POLITICS AND ECONOMIC POLICY IN WESTERN DEMOCRACIES SOCIAL POLICIES IN WESTERN INDUSTRIAL SOCIETIES
Public Health Policies and Social Inequality Charles F. An drain Professor of Political Science San Diego State University
Charles F. Andrain 1998 Softcover reprint ofthe hardcover 1st edition 1998 978-0-333-72695-2 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London WI P 9HE. Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The author has asserted his right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 1998 by MACMILLAN PRESS LTD Houndmills, Basingstoke, Hampshire RG21 6XS and London Companies and representatives throughout the world ISBN 978-1-349-40606-7 DOI 10.1057/9780230376878 ISBN 978-0-230-37687-8 (ebook) A catalogue record for this book is available from the British Library. This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. 10 9 8 07 06 05 7 6 5 4 04 03 02 01 3 2 1 00 99 98
Contents List of Tables Preface 1 Introduction: Politics and Health Social Changes and Health Policy Policymakers, Citizens, and Policy Analysts Conclusion Vlll lx 1 3 6 8 PART I MODELS OF HEALTH CARE SYSTEMS 11 2 The Entrepreneurial Model The United States Canada Conclusion 3 The Organic Corporatist Model Germany The Netherlands Japan France Conclusion 4 The Social Democratic Model Sweden Britain Conclusion 19 20 29 36 40 41 45 50 54 59 63 65 70 78 v
Vl PART II Contents EXPLANATIONS OF PUBLIC HEALTH PROGRAMS 83 5 Political Culture and the Meaning of Health 88 Causal Attributions and Policy Preferences 89 Hierarchism 93 Competitive Individualism 94 Egalitarianism 96 Fatalism 98 Political Opinion and Health Programs 99 National Public Opinion 100 Political Party Preferences 103 Business and Labor Views 108 Attitudes of Medical Personnel 109 Conclusion 110 6 Political Power and Policy Changes 113 Pluralism: Advocacy Coalitions and Policy Negotiations 116 Institutionalism: The State and Social Groups 125 Marxism: The State and Class Mobilization 132 Conclusion 143 7 Rational Choice and Market Efficiency 147 The Meaning of Rationality 149 Health Care Markets and Competition: Assumptions vs. Actual Operation 153 Efficiency of Health Care Systems: Meaning and Measurement 156 Entrepreneurial Systems 159 Organic Corporatist Systems 167 Social Democratic Systems 172 Conclusion 177
Contents vu PART III EVALUATIONS OF HEALTH POLICIES AND OUTCOMES 181 8 Public Policies and Health 184 Theory of Social Opportunities 185 Social Stratification and the Causes of Health 191 Environmental Causes 195 Individual Causes 199 The Impact of Public Policies on Health 202 Policies toward Income Equality 204 Workplace and Housing Regulations 205 Public Policies, Individual Attitudes, and Personal Lifestyles 208 Access to Public Health Care for Mothers and Infants 213 Conclusion 217 9 Evaluating Public Health Policies 221 Equality 223 Effectiveness 226 Satisfaction 229 Conclusion 232 Notes 236 Index 282
List of Tables 7.1 Health Expenditures as a Percentage of GDP, 1960-1995 8.1 Life Expectancy and Causes of Death, 1993 9.1 Infant Mortality, 1960-1995 9.2 Life Expectancy, 1960-1995 160 192 227 228 viii
Preface In contemporary industrialized nations, social inequality influences public health policies and their outcomes on people's health. No matter how egalitarian the country, the most active policy participants - managers, administrators, professionals - have the most education, income, and organizational ties. Their public health programs shape the degree of social equality. Since World War II health care has become more available to all citizens, thereby lowering infant mortality rates and raising life expectancy. Lower-income persons benefited from these policies. Yet groups with the highest socioeconomic status still secure the best-quality health care. Despite the growth of comprehensive plans, they gain greater access to urban specialists. Everywhere rural residents, the urban poor, individuals with little formal education, and ethnic minorities receive the fewest benefits relative to their health needs. Increased access to health care facilities has hardly produced equal health among diverse socioeconomic groups. During the 1990s cost-containment measures placed higher priority on efficiency than on equal access, equal treatments for similar health needs, and programs to achieve more equal health among the population. Government officials reduced services, raised taxes, and enacted higher copayments, premiums, deductibles, and user fees. Low-income groups suffered the most from these policies. Several features characterize this analysis of public policies, social inequality, and health. First, the book takes a cross-national approach. Part I compares eight industrialized nations according to three general models. The United States embodies an entrepreneurial market model. German policy processes reflect the organic corporatist model. Swedish leaders have implemented health programs derived from a social democratic model. All three societies, as well as the five other countries, reveal aspects of diverse models. Although less influential today, the corporatist tradition has shaped Sweden's contemporary health policies. Canada combines entrepreneurialism with a few social democratic practices. German corporatism features private activities associated with the market model. The weaker French corporatism IX
X Preface operates along with a strong liberal commitment to physicians' clinical autonomy. Japan blends corporatism with private-sector entrepreneurialism. In England and even Sweden, market concepts have gained greater importance. The Dutch health care system, with its extensive pluralism, relies on all three models. This comparative approach uses general variables that pertain to diverse cases across historical time and geographic space. Probing interactions within nations as well as between countries, it applies these ordinal variables to specific situations. The main tasks revolve around formulating equivalent cross-national concepts and devising operational indicators that measure the same variable in similar ways across diverse situations. If effectively used, such a comparative approach helps realize several analytical goals: accurate description, valid explanation, insightful evaluation, and the discovery of feasible, desirable health policies applicable to many industrialized societies. Second, rather than just describing health policies according to different models, this volume explains policy contents and their outcomes. Explanatory theories comprise general propositions that specify the conditions (cultural, structural, personal) producing some outcome. We explore two general effects: the administrative, fiscal, and benefits policies as well as the health status of nations, social groups, and individuals. Comparing health policies in eight industrialized nations, Part II uses three types of theories to explain these programs. The political culture approach analyzed in Chapter 5 probes the meaning of causal attributions and policy preferences about health and health care services. Formulated by Aaron Wildavsky and Mary Douglas, cultural theories clarify the framework of political discourse - for example, the meaning of health, the causes of illness, the ability of public policies to improve health, and possible solutions to the problem. This approach can help explain why the United States has less comprehensive, egalitarian health care policies than do most other industrialized nations. Structural theories explore the political power of organizations to secure policy changes. As noted in Chapter 6, the pluralist framework of Paul Sabatier emphasizes the formation of policy coalitions as a key to understanding programmatic changes. By analyzing the groups participating in these coalitions, we can partly account for the more egalitarian health policy changes that occurred in the Netherlands than in the less pluralist German
Preface Xl system. Institutionalism assumes the dominance of state agencies over social groups. It clarifies why the British government, compared with the French and Japanese, implemented more rapid, far-reaching policy changes from the early 1980s through the 1990s. Marxist theories provide insights into class alignments and historical policy changes. For example, why after 1950 did Sweden administer more generous, egalitarian health benefits than did Canada and particularly the United States? Chapter 7 investigates the relevance of rational choice theory to explain the degree of efficiency in health care markets. Why do empirical outcomes diverge from theoretical assumptions? What marketing strategies lead to unintended consequences? How can we best measure the efficiency of health care programs, particularly the link between costs and benefits (quality of services)? What impact does market competition wield on medical professionalism, patient satisfaction, economic efficiency, and access to health services? Rational choice theorists offer answers that focus on concepts like expected utility, self-interest, strategic behavior, and instrumental rationality. In Chapter 8 a theory of social opportunities elucidates the relationships between public policies and health. This explanation assumes that cultural values, sociopolitical structures, and individual behaviors shape the origins, processes, and effects of public policies. By providing meaning to political activity and motivating people to participate in the policy process, cultural values affect their opportunities to attain policy priorities. From the structural perspective, the power of the government, political parties, social groups, and transnational organizations not only constrains policy effectiveness but also facilitates opportunities for individuals to achieve their goals. Along with these culturalstructural macrodimensions, such microvariables as personal attitudes, motivations, and perceptions shape an individual's influence over the health policy process. The interaction of these three dimensions also explains the degree of health realized by nations, groups, and individuals. Cultural values about healthpromoting behavior become institutionalized in structures and internalized by individuals. Certain structural dimensions- high income equality, low unemployment, safe working conditions, wellbuilt housing- expand opportunities for health improvements. The health experienced by particular individuals depends not only on these cultural and structural conditions but on certain
Xll Preface behavioral variables: genetic predispositions, individual orientations (information, attitudes, motives, perceptions), personal lifestyles, contacts with social support networks, and the individual use of health services. These personal conditions may increase or limit opportunities for health. Third, this volume examines health policies from an interdisciplinary perspective. Rather than use a biomedical model or neoclassical economic framework, it applies a holistic approach to explain health programs and their outcomes on people's health. The holistic overview synthesizes the findings of political scientists, sociologists, economists, psychologists, and health science researchers. Aggregate data from statistical yearbooks and survey data from national samples indicate the complex interactions among cultural values, structural conditions, and personal information, attitudes, motivations, perceptions, and actions. From the holistic perspective, sociopolitical conditions, not only personal behaviors, produce better health. Assuming that illness stems partly from social causes, holists support public policies that expand the structural and cultural opportunities for healthy living. Public policies that provide preventive services and egalitarian access to comprehensive, universal programs can promote health improvements more effectively than policies relying on curative medicine. Using this holistic framework, Chapter 9 evaluates public health policies according to several criteria: public satisfaction with national health programs, their effectiveness in improving health, and equality of access, treatment, and outcome. Like making public health policies, producing a book is a collective endeavor that involves several individuals. At San Diego State University, I received a sabbatical grant that enabled me to gather information in the 1994-1995 academic year. During the last decade three Political Science Department chairmen have provided intellectual support. They include William A. Schultze, Louis H. Terrell, and E. Walter Miles. SDSU graduate students Dean Marrone and John Perretta helped prepare the manuscript for publication. I also appreciate the encouragement of T. M. Farmiloe, publishing director of Macmillan, and Niko Pfund, director of the New York University Press. This volume represents the fourth one that Anne L. Leu has processed for me since 1987. As always, she performed her work with efficiency, patience, and grace.