David Wilsford

States Facing Interests: Struggles over Health Care Policy in Advanced, Industrial Democracies

Given alarming fiscal imperatives, states and interests in all advanced industrial democracies have struggled over health care policy. I explore the interface between state autonomy in health care policy and the political mobilization of provider interests, especially physicians. Evidence from Germany, Japan, Canada, and Great Britain suggests that, longitudinally, policy makers everywhere have tried to increase state autonomy in health care, and this has generally triumphed over even effectively mobilized providers. The countries that have most successfully restrained the growth of health care expenditures--while still providing ready access to relatively high-quality care--are those where states have most actively restrained both demand- and supply-side system interests in policy making. In each country, states have increasingly articulated their own greater capacities in health care policy, pushed to do so by the imperatives, especially fiscal, embedded in the policy domain.

State Autonomy, Policy Paralysis: Paradoxes of Institutions and Culture in the French Health Care System

In this article, we assess the recent performance of the French state at containing costs in health care using political science concepts such as path dependency and incentives, which are central to an economic approach. The article focuses on institutional capacities and cultural immobilism and attempts to lay bare the tensions at play in seizing (or not) opportunities for structural change. In particular, we attempt to delineate what constitutes real change in this policy arena (big reforms versus the accumulation of many small policy movements) and to understand the variables at play in the coming together of conjunctures that provide for the big, as well as the underlying structures that allow the accumulation of the small. Except in cases of favorable conjuncture, the analysis bodes very ill for nonincremental reform and, indeed, for significant change over the long term.

Reforming medical governance in Europe. What is it about institutions

This article presents a cross-national analytical framework for understanding current attempts to reform medical governance - in particular, those by third parties to control the practice of medicine. The framework pays particular attention to the ways in which institutions shape policy reform. The article also outlines the main comparative findings of case studies of selected reforms and associated processes of negotiations in Denmark, Germany, Italy and the United Kingdom. These four countries were selected because they are characterised by theoretically interesting variations in the institutional contexts of medical governance. The analysis suggests that although all the four countries have pushed for more control over the way in which doctors practise medicine, in response to similar imperatives, each country differs in the path it has taken. More specifically, the instruments and techniques brought to bear in each case vary considerably and are directed by a countrys political institutions towards a unique path.

The Cohesion and Fragmentation of Organized Medicine in France and the United States

The French and American medical professions share similar historical bases for strong political and economic market positions. As professions, the attributes of common education, ethics, and mission tend to keep physicians together in their political organization. But the medical professions in both France and the United States are also subject to intraprofessional forces of division, such as the conflicts which often oppose generalists to specialists. Although organized medicine in France and the United States shares these commonalities, there is a very important difference between the two countries. The French profession tends toward organizational particularism, both ideologically and nonideologically, which serves to splinter it in ways inimical to the interests of the medical profession. By contrast, the American medical profession tends to organize universally-that is, its organizational base is much more often one of unity and accommodation toward the divergent interests of physicians. Thus, organized medicine in the United States has more easily fought off political and economic pressures coming from government and the private sector-but by no means with total success. On the other hand, highly fragmented organized medicine in France has experienced an almost linear decline in the face of pressures coming from a determined and strong state.

The Logic of Policy Change: Structure and Agency in Political Life

Policy universes are usually characterized by stability, even when stability represents a suboptimal state. Institutions and processes channel and cajole agents along a policy path, restricting the available solution set. Herein, structure is usually to the fore. But what of agency? Do no actors choose? In fact, they do, even in policy environments of incrementalism, even amid hostility. But where agency makes for momentous change is during the punctuations of long policy equilibriums, perfect storms enabling nonincremental movement onto a new policy trajectory, departing from the old path. On both levels, the interaction effects of both structure and agency make a difference--incrementally in the first case, nonincrementally in the second. Its not just one damn thing after another, nor does just anything go.

Ideas, institutions, and resources.

�� Simply put, the goals of any health care system in an advanced industrial democracy are threefold and manifest: (1) provide good care to (2) pretty much the whole population (3) without breaking the bank to do so. The corners of this triangle are quality, equity, and cost. While these combined goals may be manifest, they are also manifestly tricky —p erhaps virtually intractable —i n all the societies under investigation here in this issue. As Jean-Pierre Poullier and Simone Sandier summarize for the French case: “health policy objectives are straightforward and widely shared. . . . [But] mismatches between intent and outcomes have been observed throughout; the future holds more unknowns. Broadly speaking, we can identify two general approaches to the seeking of these health care system goals. The first approach, especially evident in the United States, emphasizes the role of private forces, which may or may not be market ones. These forces interact in a fairly free manner over time to end up resulting in a system—de facto rather than by any overarching design. In this system, the role of the government, or state, is relegated to the margins, a minor referee guarding against some but not all outrageous inequities, perhaps ineffectually coaxing some parties along. Ideologically, in this system, health care is not a “right” or a “due,” but rather a private good, to be obtained according to the individual’s means. The goals-oriented result of such a system has been to (1) provide lots of extremely top-quality care (“rescue medicine”) to (2) only segments of the population, leaving behind other large swathes, while (3) spending

Comparative Studies and the Politics of Modern Medical Care

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America's health care dilemma: not a pretty sight

Health Economics, Policy and Law / Volume 2 / Issue 03 / July 2007, pp 341 346 DOI: 10.1017/S1744133107004203, Published online: 24 August 2007 Link to this article: http://journals.cambridge.org/abstract_S1744133107004203 How to cite this article: DAVID WILSFORD (2007). Americas health care dilemma: not a pretty sight. Health Economics, Policy and Law, 2, pp 341-346 doi:10.1017/S1744133107004203 Request Permissions : Click here

Paying the Hospital

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