The enactment of national health insurance: a Boolean analysis of twenty advanced industrial countries

The scholarly literature on health care politics has generated a series of hypotheses to explain U.S. exceptionalism in health policy and to explain the adoption of national health insurance (NHI) more generally. Various cultural, institutional, and political conditions are held to make the establishment of some form of national health insurance policy more (or less) likely to occur. The literature is dominated by national and comparative case studies that illustrate the theoretical logic of these hypotheses but do not provide a framework for examining the hypotheses cross-nationally. This article is an initial attempt to address that void by using Boolean analysis to examine systematically several of the major propositions that emerge from the case study literature on the larger universe of twenty advanced industrial democracies. This comparative analysis offers considerable support for the veto points hypothesis while still finding each of the factors examined to be relevant in certain scenarios. We conclude with a discussion of the implications of these findings for future research and for advocates of national health insurance in the United States.     

Emergent patterns in the regulation of pharmaceuticals: institutions and interests in the United States,Canada, Britain,and France

Although industrialized nations regulate pharmaceuticals to ensure their safety and efficacy, they balance these concerns with those related to the timeliness of the approval process and the burdens involved in meeting regulatory criteria. The United States, Canada, Britain, and France have adopted different approaches to the regulation of pharmaceuticals that place varying emphases on these competing goals and involve the participation of private interests to different extents. The regulatory approval processes and the government-industry relationships inherent within them are compared in the United States, Canada, Britain, and France by analyzing five features that distinguish the U.S. pluralist from the European corporatist approaches to policy development: representation (internal versus external), process (closed versus open), stance (informal, accommodative versus formal, adversarial), institutional power (fragmented versus centralized), and resources. An institutional framework further characterizes these approaches as based on models of managerial discretion and adjudication (United States), consultation (Canada), and bargaining (Britain, France) to clarify the patterns that emerge. While the approach that most effectively supports product safety involves managerial discretion as occurs in the United States, formal mechanisms for negotiation might be incorporated rather than a reliance on the judicial process. In an era of globalization and regulatory harmonization such divergence has significant implications. First, where harmonization in Europe involves the mutual recognition of one country's product licensing decision by the others, differences in evaluative processes remain important. Second, as harmonization leads to a common set of regulatory criteria, the criteria adopted tend to be those of nations with the least stringent regulatory standards, making evident the need for more responsive systems of post-market surveillance to protect the public interest.     

An end to a consensus on health care in the Federal Republic of Germany?

Over the past fifteen years the national government in the Federal Republic of Germany has animated the political debate about rising health care expenditures. However, it has only provided health policy leadership by shifting the burden of financing health and medical care to others. This paper presents three cases that illustrate the political and institutional constraints inherent in the German policy process that limit the proposal and implementation of appropriate policy solutions to rising health care costs. Cost controls have been inhibited because of the near-universal entitlement of national health insurance, the access all social groups have to advanced medical care, and policies targeted at providers rather than users of health services. The paper also underscores the past and future importance of regional policy coalitions in shaping national health policy.     

Policy change and health care research

Explaining policy change is one of the most central tasks of contemporary policy analysis. Reacting to overly rigid institutionalist frameworks that emphasize stability rather than change, a growing number of scholars have formulated new theoretical models to shed light on policy change. Focusing on health care reform but drawing on the broader social science literature on policy and politics, this article offers critical perspectives on the institutionalist and ideational literatures on policy change while assessing their relevance for analyzing change in contemporary health care systems. The last section sketches a research agenda for studying policy change in health care.     

What determines public health expenditures in Pakistan? Role of income, urbanization and unemployment

What determines public health care expenditures at the national level is an important policy question. Since the pioneering work of Newhouse (J Hum Resour 12(1):115–125, 1977) on the relationship between health expenditures and national income, this area of economic inquiry has received much attention. This paper seeks an answer to this question by estimating the factors affecting public health expenditures at the national level in Pakistan. This paper uses annual time series data from 1972 to 2009 and employing unit root and Johansen cointegration methods estimated the determinants of public health expenditures. It is estimated that all variables are integrated of order one and are cointegrated hence in a long run relationship. The income elasticity of public health care expenditures is estimated below unity (at 0.26) indicating health care is a necessity in Pakistan contrary to most of the industrialized countries. Furthermore, it is imperative that government have a larger role in allocating and directing public resources to health care in Pakistan. Urbanization and unemployment variables have elasticity values of ?1.33 and ?0.37 respectively, implying that it is costly to provide health care to residents of remote rural areas of Pakistan.     

The political management of managed care: explaining variations in state health maintenance organization regulations

In the 1990s, strong incentives for managed care organizations to control costs, once regarded as a fortuitous confluence of interests, came to be seen as antithetical to consumers' interests in quality of care. In response to this change in political climate, many states have greatly increased their regulatory control of managed care organizations since the mid-1990s. This activity is surprising in an era when public policy on health care issues is usually described as frozen, gridlocked, and/or stalemated as a result of intense activity on the part of organized interests. We take advantage of the variation in state regulations of health maintenance organizations (HMOs) to discover why some governments are able to address policy problems that are often perceived as intractable in a political if not in a true policy sense. From the history of HMOs, the backlash against managed care, and state responses to that backlash, we first extract a number of hypotheses about state regulatory activity. We then test these hypotheses with data on regulatory adoptions by states during the late 1990s and the early 2000s. Last, we discuss the findings with special attention to the role of politics in health care.     

Differences in health care spending across countries: statistical evidence

The empirical evidence available for OECD countries suggests that economic factors play a major role and that demographic factors play a minor role in explaining differences in health care spending across countries. When countries are grouped on the basis of their health care systems, some significant cross-country differences result: countries with higher transfer rates (a larger share of collective financing) are not generally characterized by higher health care expenditures, and conversely, countries with a larger share of private financing (including higher coinsurance rates) do not have lower expenditures. Rather, the opposite holds true. Similar conclusions apply to the share of public versus private production of health goods. Furthermore, the results do not support the claims of those critics of universal public insurance systems who consider the expansion of the coverage to be a major source of expenditure growth. These findings cast serious doubt on the claim that cost containment can be achieved via market reforms that rely heavily on direct consumer payments and cost sharing as instruments of financing. A comparative analysis of the historic record of the United States, Canada, and the Federal Republic of Germany generally supports these conclusions; it also suggests that a greater degree of public penetration offers a better chance for control of health spending, particularly in periods of austerity. There is a strong presumption that health care systems relying on some overall control of spending generally are more cost-effective than those relying more on decentralized mechanisms of control. Services are more equitably distributed in relation to health and payment for health services is far more progressive in the former type of system.     

The Transposition of EU Law: ‘Post‐Decisional Politics’ and Institutional Autonomy

The transposition of European Union (EU) law into national law is a significant part of the EU policy process. However, political scientists have not devoted to it the attention that it deserves. Here, transposition is construed as part of the wider process of policy implementation. Drawing on implementation theory from the field of public policy, the article outlines three sets of factors (institutional, political, and substantive) that affect transposition. Second, the article examines the manner in which eight member states transpose EU legislation, and identifies a European style of transposition. An institutionalist approach is employed to argue that this style is not the result of a process of convergence. Rather, it stems from the capacity of institutions to adapt to novel situations by means of their own standard operating procedures and institutional repertoires. It concludes by highlighting (a) the partial nature of efforts at EU level to improve transposition, themselves impaired by the politics of the policy process and (b) some ideas regarding future research.     

Child health policy in the U.S.: the paradox of consensus

The U.S. spends more of its total GNP on health services than any other nation, yet it has one of the highest infant mortality rates in the industrialized world. Young American children are immunized at rates that are one-half those of Western Europe, Canada, and Israel. In the mid-1980s, a consensus among policymakers on the need for federal action to improve child health services resulted in the expansion of Medicaid eligibility for pregnant women and young children and the separation of Medicaid eligibility from eligibility for AFDC. The current phase of child health policymaking includes discussion of much broader proposals for changes in health care financing and innovation in health care delivery. This examination of child health policy begins by reviewing the politics of maternal and child health services from the early twentieth century to the Reagan administration, including the role of feminist movements, the development of pediatrics, and the expansion of federal involvement during the 1960s. Next, the politics of Medicaid expansion as a strategy for addressing child health issues are discussed. Current critiques of child health services in the U.S. are examined, along with proposals to restructure health care financing and delivery. Central to the politics of child health policy during the 1980s and into the 1990s is the way in which child health has been defined. Infant mortality and childhood illness are presented as preventable problems. Investment in young children is discussed as a prudent as well as a compassionate policy, one which will reduce future health care costs and enhance our position in the international economy. Unlike other "disadvantaged groups," children are universally viewed as innocent and deserving of societal support. Framing child health issues in these terms helped to produce consensus on the expansion of Medicaid eligibility. Yet the issues beyond the expansion of Medicaid eligibility involve the restructuring of health care financing and delivery, and, on these issues, conflict is far more likely than consensus.     

Courts and health policy: judicial policy making and publicly funded health care in Canada

The 1982 Canadian Charter of Rights and Freedoms provided political actors with the opportunity to make rights-based challenges to public policy decisions. Two challenges launched by providers and consumers of health care illuminate the impact of judicial review on health care policy and the institutional capacity of courts to formulate policy in this field. The significant impact of rights-based claims on cross-jurisdictional policy differences in a federal regime is noted.     

Health Information Exchange in Memphis: Impact on the Physician-Patient Relationship

Health information exchanges represent one way of making medical information available to practitioners across institutional boundaries. One health information exchange in Memphis Tennessee has been operational since May of 2006 and provides information supporting care for over 1.2 million individuals. Creating such an exchange challenged traditional institutional boundaries, roles, and perceptions. Approaching these challenges required leadership, trust, sound policy, new forms of dialogue, and an incremental approach to technology. Early evidence suggests a positive impact on patient care and a change in the way providers interact with their patients and on another. Personal health records, consolidated EHR systems, and other alternative models promise to have similar impacts on the way in which providers and patients interact with one another.     

Reform, change, and continuity in Finnish health care

This article describes some essential aspects of the Finnish political and governmental system and the evolution of the basic institutional elements of the health care system. We examine the developments that gave rise to a series of health care reforms and reform proposals in the late 1980s and early 1990s and relate them to changes in health care expenditure, structure, and performance. Finally, we discuss the relationship between policy changes, reforms, and health system changes and the strength of neo-institutional theory in explaining both continuity and change. Much of the change in Finnish health care can be explained by institutional path dependency. The tradition of strong but small local authorities and the lack of legitimate democratic regional authorities as well as the coexistence of a dominant Beveridge-style health system with a marginal Bismarckian element explain the specific path of Finnish health care reform. Public responsibility for health care has been decentralized to smaller local authorities (known as municipalities) more than in any other country. Even an exceptionally deep economic recession in the early 1990s did not lead to systems change; rather, the economic imperative was met by the traditional centralized policy pattern. Some of the developments of the 1990s are, however, difficult to explain by institutional theory. Thus, there is a need for testing alternative theories as well.     

The changing process and politics of health policy in Korea

Korea recently introduced three major health care reforms: in financing (1999), pharmaceuticals (2000), and provider payment (2001). In these three reforms, new government policies merged more than 350 health insurance societies into a single payer, separated drug prescribing by physicians from dispensing by pharmacists, and attempted to introduce a new prospective payment system. This essay compares the three reforms in Korea and draws important lessons about the country's changing process and politics of health care policy. The change of government, the president's keen interest in health policy, and democratization in the public policy process toward a more pluralist context opened a policy window for reform. Civic groups played an active role in the policy process by shaping the proposals for reform-a major change from the previous policy process that was dominated by government bureaucrats. The three reforms also showed important differences in the role of interest groups. Strong support by the rural population and labor unions contributed to the financing reform. In the pharmaceutical reform, which was a big threat to physician income, the president and civic groups succeeded in quickly setting the reform agenda; the medical profession was unable to block the adoption of the reform but their strikes influenced the content of the reform during implementation. Physician strikes also helped block the implementation of the payment reform. Future reform efforts in Korea will need to consider the political management of vested interest groups and the design of strategies for both scope and sequencing of policy reforms.     

Nondecision making and inertia in Portuguese health policy

Despite there having been a positive context for initiating health care reforms in Portugal in the past fifteen years (accompanied by political consensus on the nature of the structural problems within the health care system), there has been a lack of reform initiatives. We use a process-based framework to show how institutional arrangements have influenced Portuguese health care reform. Evidence is presented to demonstrate inertia and nondecision making in three critical areas of Portuguese health policy: clarifying the public-private mix in coverage and provision, creating financial incentives and motivation for human resources, and introducing changes in the pharmaceutical market. Several factors seem to explain these processes, namely, problems in the balance of power within the political system, which have contributed to a lack of proper policy discussion; a lack of pluralism in the formation of health care policies (with low participation from citizens and high mobilization among structural interest groups); and the low priority of health care in public sector reforms. Portuguese politicians should be aware of the pitfalls of the current political system that constrain participatory arrangements and pluralism in policy making. In order to pursue health care reform, future governments will need to counterbalance the strong influence of structural interest groups.     

Public trust and privacy in shared electronic health records

The development of information and communication technology in health care, also called eHealth, is expected to improve patient safety and facilitate more efficient use of limited resources. The introduction of electronic health records (EHRs) can make possible immediate, even automatic transfer of patient data, for health care as well as other purposes, across any kind of institutional, regional or national border. Data can thus be shared and used more effectively for quality assurance, disease surveillance, public health monitoring and research. eHealth may also facilitate patient access to health information and medical treatment, and is seen as an effective tool for patient empowerment. At the same time, eHealth solutions may jeopardize both patient safety and patients' rights, unless carefully designed and used with discretion. The success of EHR systems will depend on public trust in their compatibility with fundamental rights, such as privacy and confidentiality. Shared European EHR systems require interoperability not only with regard to technological and semantic standards, but also concerning legal, social and cultural aspects. Since the area of privacy and medical confidentiality is far from harmonized across Europe, we are faced with a diversity that will make fully shared EHR systems a considerable challenge.     

Obesity, courts, and the new politics of public health

Health care politics are changing. They increasingly focus not on avowedly public projects (such as building the health care infrastructure) but on regulating private behavior. Examples include tobacco, obesity, abortion, drug abuse, the right to die, and even a patient's relationship with his or her managed care organization. Regulating private behavior introduces a distinctive policy process; it alters the way we introduce (or frame) political issues and shifts many important decisions from the legislatures to the courts. In this article, we illustrate the politics of private regulation by following a dramatic case, obesity, through the political process. We describe how obesity evolved from a private matter to a political issue. We then assess how different political institutions have responded and conclude that courts will continue to take the leading role.     

The Swedish mental health system. Past, present, and future

In sum, the evolution, strengths, and weaknesses of the Swedish mental health system are quite similar to mental health systems in other Western countries; early reliance on stand-alone, state psychiatric hospitals, followed by deinstitutionalization and development of largely ambulatory, community mental health care. This evolution has been complicated in Sweden by the multiple levels and system components, the state, the county councils and the municipalities. Unlike the United States, but similar to Britain, community mental health care in Sweden is provided by two systems; treatment (and forensic services) by the county councils' mental health providers, and generic services by the municipalities' social welfare system. The resulting division of roles and responsibilities creates a strong need for collaboration and coordination of activities on behalf of consumers. It can also have the unintended disincentives to serving more difficult consumers. All these difficulties not withstanding, the Swedish mental health system has made major stride in providing quality, appropriate care.