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.     

Improving return-to-work strategies in the United States disability programs, with analysis of program practices in Germany and Sweden

The General Accounting Office (GAO) has made recommendations for improving the disability programs by citing practices that have been successful in Germany, Sweden, and the private sector. This issue is important in the United States because the number of disability beneficiaries is growing rapidly, program costs are increasing proportionately, and few disability recipients are leaving the disability rolls to resume work activity. GAO points out that the estimated lifetime savings for removing an additional 1 percent of the disabled beneficiaries from the rolls of the Disability Insurance (DI) and the Supplemental Security Income (SSI) programs each year will ultimately reach $3.0 billion. GAO cites three specific practices as showing the most promise for returning the disabled to work. They are (1) intervening as soon as possible after a disabling event to promote and facilitate return to work, (2) identifying and providing necessary return-to-work assistance and managing cases to achieve return-to-work goals, and (3) structuring cash and health benefits to encourage people with disabilities to return to work. This article examines these suggestions to improve the rate of rehabilitation of disabled workers using research by experts on return-to-work practices in Germany, Sweden, and the United States. Experts caution that any consideration of borrowing practices from other countries needs to take into account the unique economic, social, and political elements in each country. Although other countries appear to be very successful in their rehabilitation programs, practices that are successful in one country may not necessarily work well in another. Countries have different definitions of disability and payment structures. The existence of temporary and partial awards in Germany and Sweden may ensure a number of easily rehabilitated individuals, while the U.S. vocational rehabilitation (VR) agencies have been mandated to focus on only the most severely disabled individuals. Public expenditures for vocational rehabilitation, work for the disabled, and disability benefits are much higher as a percentage of gross domestic product in Germany and Sweden than they are in the United States. Compared with the United States, Germany spent twice as much for VR, and Sweden spent 2.6 times more. Impediments to GAO's suggestions include divergent goals of the Social Security program and VR agencies, lack of availability of VR services, the timing of VR referral (which is significantly later than the onset of the disability), and little incentive for return to work built into the payment structure. The Work Incentives Improvement Act of 1999 is currently being considered by a Congressional conference committee. The bill would establish a Ticket to Work and Self-Sufficiency program and would require or authorize the Social Security Administration to demonstrate and evaluate different ways of encouraging return to work. In designing these demonstrations, early intervention after a potentially disabling illness or injury is an approach that merits serious attention.     

Political economy of agricultural policy

The present paper uses a paneldata estimation technique to combine the time series for individual countries (Australia, Canada, France, Germany, Italy, Japan, the Netherlands, Switzerland, the United Kingdom and the United States). We postulated the response of central banks in these countries to inflation, economic growth and current account surplus given the constraints to be the same among the sample countries. Differences between central bank independence come forward in a different structural pressure to lower or raise money market rates in these countries. The empirical results in this study coincide remarkably well with the legal indices of central bank independence.     

New perspectives on the public policy implications of defense and welfare expenditures in four modern democracies: 1950–1970

This article compares expenditure decisions in four “Western” democracies (Australia, Sweden, the United Kingdom, and the United States) in the policy areas of defense, health, education, and all government expenditures from 1950 to 1970. In addition, national income is used as a measure of economic growth in the four countries. The research focuses on the yearly fluctuations of expenditures and the statistical relationships existing among the variables under changing conditions. The research indicates significant departure from prior research findings and suggests that the assumption of an explicit trade-off between defense and welfare expenditures be reconsidered. In addition, when varying economic growth was examined, the research again indicates the need for reconsideration of prior relationships. Throughout, the article encourages the development of comparative policy research and theory and recommends the development of careful theoretical and methodological constructs.     

Controlling Nonconventional Expenditure: Tax Expenditures and Loans

Tax expenditures, credits and guarantees, and other nonconventional expenditures are prominent features of the public finances of the United States and other industrialized democracies. While reliable data on these practices have generally been available only for a decade or less, there is reason to believe that these types of transactions now constitute a larger share of total public expenditure than they did in the past. This article discusses the concepts arid implications of two types of nonconventional expenditures—tax expendituures and loans—as well as recent efforts to bring them within the scope of the budget process. The article deals mostly with American practices, but it also draws on the experiences of other democratic countries.     

Bioethical Policymaking for Advanced Medical Technologies: Institutional Characteristics and Citizen Participation in Eight OECD Countries1

Organizational characteristics of public institutions, councils, committees, and panels for bioethical deliberations were examined in eight OECD countries, that is, the United Kingdom, Germany, France, the Netherlands, Denmark, the United States, Canada, and Japan. Their jurisdiction, membership composition, modes of agenda setting, and appraisal systems were examined, as was their utilization of public involvement measures. Questionnaire surveys and structured interviews were conducted with representatives of parliamentary offices, ministries, and other institutions for ethical deliberations, both public and private, in the eight countries. Confirmation of survey results was made by close follow‐up communications. Since the early 1980s, all the countries studied have established public institutions for policy deliberation on bioethical issues. While legislatures, for example, Parliament, sometimes convene special commissions or expert panels on an ad hoc basis, most of the permanent institutions are affiliated with ministries of health, science, or technology. The composition of core panel members was quite similar across institutions as well as among countries, generally composed of 10 to 15 experts. Many institutions have experimented with some forms of public involvement measures, although public involvement is not routinely incorporated in the policy process, except in Denmark, the Netherlands, and Canada. The study describes the current public institutions and their practices for bioethical policy deliberations. Exchange of experience and knowledge among the institutions is advisable to improve their performance.     

National styles of regulation: Child care in three countries

An analysis of child care regulations in Germany, Sweden, and the United States reveals distinctive national policy styles. A ‘social constructionist’ perspective, with its emphasis on variable problem definitions, helps to explain such differences. However, a full understanding of regulatory differences requires attention to regulatory solutions as well. By disaggregating the concept of regulation, we are able to demonstrate rather different rank-orderings of our three countries in their regulatory solutions. We attribute these differences to cultural, institutional, and political characteristics of the three countries.     

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.     

Delegation and Institutional Design in Health‐Care Rationing

The delegation of decision‐making powers to nonmajoritarian, independent agencies has become a significant phenomenon in more and more policy areas. One of these is the health‐care sector, where decisions on the range of services covered within public systems have, in most developed countries, been delegated to specialized bodies. This article offers an analytical framework that seeks to grasp the empirical variety and complexity of delegative processes and appointed institutions. The framework is used to describe decision‐making processes and institutions in six countries: Austria, Germany, Norway, Sweden, New Zealand, and the United Kingdom. We find that, although constrained by preexisting institutional structures and traditions, delegators enjoy a considerable degree of discretion in their institutional design choices and engage in strategic design and redesign of appointed bodies.     

THE HEALTH CARE MARKETPLACE; PERSPECTIVES ON A SYSTEM IN TRANSITION

Within the last 35 years health care expenditures have increased from $12 billion t o over $350 billion. Recent concern over these costs have led to a reevaluation of the health care delivery system in the United States. This paper reviews four emerging cost containment models. The discussion focuses on the "market-likell incentives introduced in to the health care delivery system by such strategies.     

The political economy of IMF forecasts

We investigate the political economy of IMF forecasts with data for 157 countries (1999–2005). Generally, we find evidence of forecast bias in growth and inflation. Specifically, we find that countries voting with the United States in the UN General Assembly receive lower inflation forecasts as domestic elections approach. Countries with large loans outstanding from the IMF also receive lower inflation forecasts, suggesting that the IMF engages in “defensive forecasting.” Finally, countries with fixed exchange rate regimes receive lower inflation forecasts, suggesting the IMF desires to preserve stability as inflation can have detrimental effects under such an exchange rate regime.     

The decline of special circuits in developed country housing finance

Abstract

Housing finance traditionally has been an area of intervention by governments, especially through the creation of special circuits for funding flows. This paper analyzes these special circuits in five developed countries (Denmark, France, Germany, United Kingdom, United States) and tracks their evolution through the 1980s under the pressures of inflation, interest‐rate volatility, deregulation, and integration of international financial markets.

Political and market forces seem to have eroded both the reasons for having special circuits and the ability to maintain them. All of the subject countries experienced some degree of decline in these circuits and moved toward integration of housing finance within competitive, market‐driven financial systems. This trend will probably continue in the 1990s.     

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.     

Mandating private pensions: experience in four European countries.

This study examines the experience of four countries--the Netherlands, Sweden, Switzerland, and the United Kingdom--in which the mandating of private pensions exists or has been considered. Proposals to mandate private pensions in the United States have been introduced in Congress several times. The analysis of foreign thinking presented here provides a background on the reasoning behind such a policy and on the integration of private and public systems and the problems involved. A prime reason for mandating private pensions--instead of seeking higher social security benefits or additional social security layers--has been the pressure to avoid higher payroll taxes. Some countries already had such high contribution rates that they sought other means to improve benefits. Adding a layer of private pensions, it was thought, does not involve Government mechanisms and keeps the money in the private sector. Yet mandating by law creates many problems, and no country has fully implemented such legislation.     

Regulating Rule‐Making via Impact Assessment

In their attempt to promote “better regulation,” governments have ended up with increasing regulation of rule‐making. Regulatory impact assessment (RIA) is a manifestation of this trend. This article draws on the positive political economy hypothesis that RIA is an administrative control device. Rational politicians—positive political economy argues—design administrative requirements to solve problems of political uncertainty. This is a rather abstract hypothesis but with clearly observable implications. Empirical analysis on Canada, Denmark, the Netherlands, Sweden, the United Kingdom, the United States, and the EU shows that the modes and level of control vary, with almost no evidence supporting the positive political economy hypothesis in Denmark and Sweden and more robust evidence in the other cases, especially the United States and the United Kingdom. The EU scores high, but control has both a political component and an infra‐organizational dimension. In between the extremes I find modest levels of political control in Canada and the Netherlands.     

Regulating the computer: comparing policy instruments in Europe and the United States

Abstract. The introduction of information technology to governmental agencies has raised considerable concern for the erosion of personal privacy in most advanced democratic states. This article compares and tries to explain the choice of policy instrument in four key countries (Sweden, the United States, West Germany and the United Kingdom) to enforce the protection of personal data. Five options were available from the 'international repertoire' of solutions: voluntary control, subject control, licensing, a data commissioner and registration. The Swedes opted for licensing, the Americans rely on subject control, the Germans established a data commissioner and the British chose a registration scheme. In no state, however, were these decisions made from a synoptic analysis of all possible options. Nor did a process of policy diffusion occur. Rather, a combination of domestic constraints seemed to filter out unacceptable options and produce a bias in favour of the resulting policy instrument. In the United States and Sweden, this bias resulted from perceived constitutional imperatives; in West Germany and Britain, the position and power of the respective national bureaucracies produced stiff resistance, a conflictual policy process and resulting policy instruments with few, if any, precedents in their respective systems.     

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.     

Citizenship Tests: A Comparative, Communitarian Perspective

The history, nature and scope of citizen naturalisation tests are briefly examined in this article, as well as their political and social applications. A comparison of tests from the United States, the United Kingdom, the Netherlands and Germany highlights the ways in which these tests are used as immigration controls rather than as a way to establish preparation for citizenship. The difference in the content of the tests also reveal alternative conceptions of citizenship including authoritarian, liberal and neo-communitarian.     

The Media as Political Agenda-Setters: Journalists’ Perceptions of Media Power in Eight West European Countries

Studies in different countries have shown that the media can influence the attention politicians devote to different issues. However, knowledge about the cross-national contingencies of the political agenda-setting power of the media is limited. This study compares the perceptions of journalists of the political agenda-setting power of the mass media in eight parliamentary democracies with varying media and political systems: Belgium, Denmark, Germany, Norway, Spain, Sweden, The Netherlands and the United Kingdom. Building on a power balance perspective, the article looks at the autonomy of the media system (audience reach and political control) and the concentration of power in the political system (number of political parties, concentration of executive power) to contextualise the role of the media in political agenda-setting. Journalists perceive most media influence in Norway and Sweden and least in Spain. The results indicate that the power balance between the media and political actors to a large extent reflects the institutional structure of the political system, but that media characteristics such as the autonomous position of television should also be taken into account.     

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.