Federalism and suitable housing for the frail elderly: A comparison of policies in Canada and the United States

Abstract

The frail elderly have special multidimensional housing needs beyond affordability, including shelter that is more adaptive to reduced function and offers supportive services. Suitable housing for this population comprises three policy areas—housing, health care, and social services. In a federal system, development and implementation of policies in these areas involves participation of several levels of government and the nongovernmental sector. This paper uses federalism as a conceptual framework to examine and compare these policy areas in Canada and the United States.

In both countries, general national housing policies—relying heavily on the nongovernmental sector and characterized by joint federal‐provincial programs in Canada and by important local government roles and age‐specific programs in the United States‐have benefited the elderly. The effects of such policies on the frail elderly, however, have been less positive because of the general lack of essential human services and, to a lesser degree, health care that enables them to live outside institutions. This is especially true in the United States, where health care policy is fragmented and is dominated by a private insurance system, partial federal financing of health insurance for the elderly, and tense federal‐state relations in financing health care for the poor. Although Canadian policies and programs operate autonomously and more uniformly within a national health plan, neither country has a universal, comprehensive long‐term care system. Geographically diverse patterns of social services, funded by grants to states and provinces and the nonprofit sector, are common to both countries. However, the United States has inadequately funded age‐specific programs and has relied on a growing commercial service provision. Housing outcomes for frail elders are moving in the right direction in both countries; however, Canada seems to be better positioned, largely because of its health care system. As increased decentralization continues to characterize the three policy areas that affect suitable housing for frail elders, the United States can learn from Canada's negotiated federalism approach to more uniform solutions to merging housing and long‐term care.     

Impact of Political Structures and Informal Political Processes on Health Policy: Comparison of the United States and Canadab

A number of factors, including cultural, social, economic, political, and historical, influence policy. United States and Canada's health care systems are the conscious and subconscious outcomes of formal political structures and informal political processes. The Canadian parliamentary political system encourages centralized, organized, planned policy in health care. However, this is accomplished at the risk of leaving some individuals—physicians in this case—quite frustrated. American constitutional features, the presidential system, weak political parties, and the tireless participation of interest groups in the political process all function to discourage the formation of highly rational and efficient policy. While few special interests are ever completely satisfied with the legislation produced, seldom is any organized group completely thwarted. Therefore, it is no surprise that a tightly integrated national program of universal health insurance was not adopted by Congress in 1993–1994. Political structures and processes discourage effective, comprehensive health care reform in the United States.     

THE HEALTH CARE FINANCIAL CRISIS: REORGANIZATION AND EVIDENCE-BASED MEDICINE AS A RESPONSE TO AN "UNHOLY TRINITY"

The key issues of the health care system are often conceptualized as involving three basic dimensions: 1) the quality of health care provided, 2) access to the health care system, and 3) the cost of health care. Following two decades of rapidly escalating health costs throughout advanced industrial societies, the relationships among these three dimensions now constitute what has been called an “unholy trinity” in that improvements along one dimension will almost inevitably provoke problems in terms of one or both of the others. This symposium examines two distinct types of reform that have been developed in response to the crisis in health care costs. The first focuses upon attempts to reorganize existing institutions in order to make them more effective and cost‐efficient. The second considers the move toward “evidence‐based medicine,” that is, more critically evaluating health care outcomes to make sure that treatments are effective and cost‐efficient.     

Effect of testing and social distancing measures on COVID-19 deaths in India: Role of pre-existing socio-economic factors

We examine the effect of testing and social distancing measures on the severity of COVID19 across Indian states during the 68th day nationwide lockdown period. We also explore whether pre-existing socio-economic factors such as quality of health care and the ability to practice social distancing influences the effect of these policy measures across states. Using daily level data between April 1 and May 31 for 18 of the major states, we find that both testing and social distancing have a negative effect on COVID-19 fatalities in India. Further, testing is more helpful in reducing CFR for states with lower per capita health expenditure and weaker medical infrastructure. This highlights how ramping up testing can aid states that have a weak health care system through the detection of infection, contact tracing and isolation. In contrast, social distancing measures are more effective in states that are less populous and have lesser people dwelling in single-room houses. Our results confirm the role of pre-existing institutional factors in shaping the effect of policy actions on health outcomes.     

India's experience—national,community, public or private health?

India, as the largest democracy, second most populous country, ninth largest industrial power and fifteenth poorest nation, has in respect of health care to be considered as a special case among developing countries. Nevertheless, the identification in India, as an alternative to national welfare provision, of opportunities for returning social and economic responsibilities for health care to local communities is important for both developing and developed countries. This article outlines and comments upon recent developments in providing primary health care in rural communities in India. It concludes by examining possible parallels between self-sustaining community health schemes and the search in developed countries for community and personal involvement so as to overcome emergent limitations of professionalized and welfare systems of care.     

Centralisation versus regionalisation: Designing the Sixth National Mental Health Plan

In response to the recent Productivity Commission report into mental health, the previous Federal Government announced its intention to produce a new national agreement that lays the platform for Australia's sixth national mental health plan. It has been recommended mental health move to a more regional model of governance and planning, away from a centralised, top-down approach, partly in response to broader reforms affecting health care, and partly in direct response to consistent inquiry evidence that the mental health system remains in crisis. The past 30 years of mental health planning have been centralised. Successive national plans set a broad framework, with real decisions about mental health funding and service allocation made in the health departments of our capital cities. Will the next plan sponsor or inhibit regionality in mental health planning? This paper assesses Australia's historical approach to health planning particularly as it affected mental health and the costs arising. In learning these lessons, we propose the necessary ingredients to facilitate a regional, innovative, and effective approach to decentralised planning, for better mental health outcomes. We cannot afford to replicate the failed planning approaches of the past.     

Ideas and inducements in mental health policy.

Between 1946 and 1963, federal officials sought to change the national practice of providing mental health care, away from state-run mental institutions and toward outpatient care based in local communities. These policy makers relied on two policy instruments, ideas and inducements. Both instruments contributed to unexpectedly significant changes in federal, state, and local policy. I conclude that a policy instrument framework helps to disentangle the strands of successful public management, and that it is useful to think of ideas as policy instruments that offer leverage on policy outcomes.     

Rental Housing Assistance and Health: Evidence From the Survey of Income and Program Participation

Interest in the health impacts of renter housing assistance has grown in the wake of heated national discussions on health care and social welfare spending. Assistance may improve renters’ health by offering (a) low, fixed housing costs; (b) protection against eviction; and (c) access to better homes and neighborhoods. Using data from the Survey of Income and Program Participation and econometric analysis, I estimate the effect of receiving assistance from the public housing or Section 8 voucher programs on low-income renters’ reported health status and spending. Assisted renters spent less on health care over the year than unassisted low-income renters did, after controlling for other characteristics. This finding suggests that assisted housing leads to health benefits that may reduce low-income renters’ need to purchase health services. Voucher holders’ lower expenditures are influenced by their low, fixed housing costs, but public housing residents’ lower expenditures are not explained by existing theory.     

Vertical Competition in the Spanish National Health System (NHS)

In unitary states, competitive decentralisation structures can take place by increasing the visibility of politically accountable jurisdictions in certain policy responsibilities such as health care. Drawing from the Spanish decentralisation process we examine the mechanisms (and determinants) of vertical competition in the development of health policies in the Spanish National Health System. The Spanish example provides qualitative evidence of vertical competition that assimilates government outcomes of unitary states to that of federal structures. The Spanish experience indicates that the specific vertical competition mechanisms in place until 2002 are likely to be responsible for significant policy innovation and welfare state development.     

Health care expenditures in nine industrialized countries, 1960-76

This article reports the findings of a study developed to compare health care costs in the United States with those of eight other industrially advanced countries over the period 1960-76. All of the countries studied were found to share with the United States the problem of increased health care spending that has outpaced inflation in other sectors of the economy and continues to consume a growing share of national resources. The American growth rate in these expenditures has, in fact, been lower than that of all other coutries. Though U.S. health care expenditures have traditionally been relatively high when measured as a share of gross national product, Canada outspent the United States in this respect during the 1960's. In most recent years, West Germany, the Netherlands, and Sweden have devoted a larger share of GNP to health care than has the United States.     

Male Perpetrators of Domestic Violence: How Should We Hold Them to Account?

Domestic violence is now widely acknowledged as being a significant social, health and legal issue. At both a national and transnational level governments have sought to develop strategies built upon prevention, support for victims and holding perpetrators to account through criminal justice sanctions. However, the current paradigm that informs the policy response to most perpetrators of domestic violence has failed to deliver the outcomes required, in terms of a reduction in levels of recidivism or the improved safety of women and children. It is argued that holding men to account through external controls has failed and that interventions should support men to take responsibility for their own behaviour.     

Toward a social indicators model of aggregate American political behavior: 1948–1976

Using time series data from 15 post-World War II congressional elections, a nine-equation social indicators model of aggregate American political behavior is estimated. Six exogenous social and economic conditions and nine endogenous political variables are linked in a schematic flow across three sectors of the national polity. Findings indicate that relatively short-term social and political conditions exert greater effects on election outcomes than do long-term partisan alignments. The party composition of the executive and legislative branches of the federal government affects defense expenditures as a proportion of all budgetary outlays, but has only weak impact on health and education expenses. Criticisms and suggestions for future work are discussed.A preliminary version of this paper was presented at the American Sociological Association Meetings in San Francisco in August 1975.     

Social indicators for health planning and policy analysis

The concept of health involves two dimensions: The level of function at a point in time and the probability of transition to other levels at future times. By applying measured social values to the distribution of the population among a set of levels, a Function Status Index aptly summarizes the Level-of-Well-Being of a population at a point in time. By incorporating empirically determined transition probabilities into a simple stochastic model, a Quality-Adjusted Life Expectancy can be computed that approximates a comprehensive social indicator for health. The indicators possess the statistical properties required for time series and interpopulation comparisons, for studying outcomes and quality of medical care, and for health system optimization in planning and policy analysis.     

National health insurance: Some lessons from the Canadian experience

In the current American debate over national health insurance an examination of the Canadian governmental experience is very instructive. Canada is enough like the United States to make the effects of Canadian health insurance policies rather like a large natural experiment. The Canadian experience—universal government health insurance administered by the ten provinces with some fiscal and policy variations—can be used to predict the impact in the United States of proposed national health insurance plans on the medical care system, and the reaction of mass publics and national policymakers to these effects.The central purpose of the Canadian national health insurance was to reduce and hopefully eliminate financial barriers to medical care. In this it succeeded. But it also produced results which Canadian policymakers never anticipated: essentially unexpected side-effects on cost, quality, organization, and manpower distribution of the particular national health insurance program adopted. It should be cause for concern, the article concludes, that most of the prominent American national health insurance proposals resemble the Canadian program in failing to provide a single level of government with both the means and incentives to curb the inflationary effects of national health insurance. The lesson from Canada is that unless the system has very strong anti-inflationary mechanisms and incentives built into it, national health insurance will feed the fires of medical inflation despite great formal governmental authority to control it.     

A shrinking state? Politics,economics and private health care in Thailand

This article explores the political and economic forces involved in the development of privatization policies within the health care sector in Thailand. It is suggested that many of the motivating factors behind private sector growth are outside of the health sector; the general macroeconomic environment and tax incentives have stimulated private sector expansion. Within the Ministry of Public Health a preoccupation with improving care in rural areas and an unclear policy line on the private sector has facilitated this expansion. Only recently has private sector growth come to the policy agenda. During this lag period a number of interest groups have developed. It will be difficult to overcome these entrenched interests in order to change policy direction. Meanwhile, problems of rapid cost inflation and inequity face the Thai health care system. Although this case study focuses upon the health care sector in Thailand it would appear relevant both to other sectors and to other countries. The relationship between development models based upon pro-private, pro-market tenets and the establishment of a satisfactory social policy is questioned.     

INTERNATIONAL HEALTH CARE REFORM: THE NEED FOR COMPREHENSIVE MICRO-COMPARATIVE ANALYSIS

Microcomparison, or single‐component analysis, of health care systems offers a potentially better basis for reform than traditional macrocomparison analysis of aggregate elements. Using macroanalysis, available evidence shows that Germany provides cheaper but more effective hospital care than the United States. To find the causes for this outcome, we developed a microanalytic model of hospital administrators’ perceptions, financial ratios, medical outcomes, and pharmaceutical costs. However, only data on pharmaceutical costs were available and similar in both countries. Our significant outcome was development of a microcomparative model that gives world medical care providers new criteria for analyzing and improving cost to care rafios.     

How do international human rights influence national healthcare provisions for irregular migrants?: A case study in France and the United Kingdom

Debates about human rights have often questioned their potential for generating rights at national levels. In this article, we use the case of irregular migrants' access to health care in the United Kingdom and France to explore the extent to which international human rights influence national health care provisions for irregular migrants. We explore the extent to which health care access and provision for irregular migrants in these two countries is in agreement with international human rights. In so doing, we examine what constitutes an infringement of the international human right to health care. Finally, we sketch out some hypotheses about the role played by different state structures in the implementation of human rights norms, comparing the United Kingdom with France. We argue that, although international human rights often have a largely symbolic role in nation-state jurisdiction, they may sometimes represent a force for change.     

Electoral competition and the welfare state

The article investigates how parties compete over the welfare state by emphasising specific welfare state issues. The core argument is that two issue-specific factors determine how much parties emphasise individual welfare state issues: the character of policy problems related to the policy issues and the type of social risks involved. To test the argument, a new large-N dataset is employed, with election manifestos from Belgium, Denmark, France, Germany, the Netherlands, Sweden, and the United Kingdom. The dataset contains information on how much parties have talked about health care, education, and labour market protection in national elections since 1980. With the data at hand, it is possible to provide the first systematic investigation of how parties compete for votes over the welfare state. The approach here is able to explain the empirical fact that health care is consistently receiving increased attention everywhere, while particularly labour market protection has witnessed a decline in attention.