Carolyn Hughes Tuohy

How Does Private Finance Affect Public Health Care Systems? Marshaling the Evidence from OECD Nations

The impact of private finance on publicly funded health care systems depends on how the relationship between public and private finance is structured. This essay first reviews the experience in five nations that exemplify different ways of drawing the public/private boundary to address the particular questions raised by each model. This review is then used to interpret aggregate empirical analyses of the dynamic effects between public and private finance in OECD nations over time. Our findings suggest that while increases in the private share of health spending substitute in part for public finance (and vice versa), this is the result of a complex mix of factors having as much to do with cross-sectoral shifts as with deliberate policy decisions within sectors and that these effects are mediated by the different dynamics of distinctive national models. On balance, we argue that a resort to private finance is more likely to harm than to help publicly financed systems, although the effects will vary depending on the form of private finance.

Reform and the Politics of Hybridization in Mature Health Care States

This article examines the cases of three health care states -- two of which (Britain and the Netherlands) have undergone major policy reform and one of which (Canada) has experienced only marginal adjustments. The British and Dutch reforms have variously altered the balance of power, the mix of instruments of control, and the organizing principles. As a result, mature systems representing the ideal-typical health care state categories of national health systems and social insurance (Britain and the Netherlands, respectively) were transformed into distinctive national hybrids. These processes have involved a politics of redesign that differs from the politics of earlier phases of establishment and retrenchment. In particular, the redesign phase is marked by the activity of institutional entrepreneurs who exploit specific opportunities afforded by public programs to combine public and private resources in innovative organizational arrangements. Canada stands as a counterpoint: no window of opportunity for major change occurred, and the bilateral monopoly created by its prototypical single-payer model provided few footholds for entrepreneurial activity. The increased significance of institutional entrepreneurs gives greater urgency to one of the central projects of health policy: the design of accountability frameworks to allow for an assessment of performance against objectives.

Models of professional regulation: institutionalizing an agency relationship

The regulation of medical practice can historically be understood as a second-level agency relationship whereby the state delegated authority to professional bodies to police the primary agency relationship between the individual physician and the patient. Borow, Levi and Glekin show how different national systems vary in the degree to which they insist on institutionally insulating the agency function from the promotion of private professional interests, and relate these variations to different models of the health care state. In fact these differences have even deeper roots in different “liberal” or “coordinated” varieties of capitalist political economies. Neither model is inherently more efficient than the other: what matters is the internal coherence or logic of these systems that conditions the expectations of actors in responding to particular challenges. The territory that Borow, Levi and Glekin have usefully mapped invites further exploration in this regard.This is a commentary on http://www.ijhpr.org/content/2/1/8.

The Politics of Medicare North and South

I am faced with a somewhat ironic task. I am asked to bring a comparative perspective to bear on a classic work by an outstanding comparative scholar of health policy. And as a Canadian, I am acutely aware of the enormous contribution its author has made to health policy debate in Canada. Yet The Politics of Medicare, for all its seminal importance, is in its first and even in its second edition one of Ted Marmor’s least explicitly comparative works. No other countries except Canada are referenced in the index, and even Canada is cited primarily in the context of its influence (or lack thereof ) as a model in American policy debates. I will therefore take some liberty with my assignment and present a comparison of American and Canadian versions of Medicare that is fundamentally informed by the empirical work and the analytic framework of The Politics of Medicare. In so doing, I hope to provide a validation of Marmor’s arguments and by extension to demonstrate the key contribution to comparative work that his analysis of American Medicare has made. As Jacob S. Hacker points out elsewhere in this review symposium, the first edition of The Politics of Medicare challenged the prevailing focus of studies of policy making in American political science— namely, a focus on interest-group politics. Marmor instead directs our attention to the behavior of political actors in institutional contexts. Although, like Graham Allison, he presents different models for interpreting that behavior, it is clear that he looks to the judgments and interactions of decision makers, not the clash of group forces, for the explanation of policy outcomes. Should there be any doubt about the validity of this approach, it is worth testing it through a comparative analysis. And indeed Marmor’s insights are resoundingly validated by two sets of comparisons of the American and Canadian cases: one drawn from the era of the first edition, and one drawn from the era of the second. Consider the era of the first edition, the founding moment of American Medicare in the 1960s. In the same period, Canadian Medicare was also being born. The pattern of development of the two health systems in the postwar period had been remarkably similar. In both nations, proposals for universal health insurance had failed in the late 1940s, to be replaced Books: Symposium on The Politics of Medicare 161