Kieke G. H. Okma

Comparative Perspectives and Policy Learning in the World of Health Care

Abstract The main point of this article is to explore the methodological questions raised by weaknesses in international comparative work in the field of health policy. The core question is how competent learning from one nation to another can take place. The article argues that there is a considerable gap between the promise and the actual performance of comparative policy studies. Misdescription and superficiality are all too common. Unwarranted inferences, rhetorical distortion, and caricatures, all show up too regularly in comparative health policy scholarship and debates. The article first describes the context of the health and welfare state reform debates during the past three decades. In almost all industrialized democracies, rising medical expenditures exacerbated fiscal concerns about the affordability of the mature welfare state. In reaction to pressure for policy change in health care, policy makers looked abroad for promising solutions to domestic problems. The following section takes up the topic of cross-national policy learning. Then, it critically reviews recent debates about health care reforms and addresses the purposes, promises and pitfalls of comparative study in health policy. The next section categorizes existing comparative health policy literature to highlight the character, possibilities and limits of such work. The concluding section returns to the basic theme: the real promise of comparative scholarship and the quite mixed performance to date.

Six Countries, Six Health Reform Models? Health Care Reform in Chile, Israel, Singapore, Switzerland, Taiwan and The Netherlands

Abstract This research contribution presents a diagnosis of the health reform experience of six small and mid-sized industrial democracies: Chile, Israel, Singapore, Switzerland, Taiwan and The Netherlands during the last decades of the twentieth century. It addresses the following questions: why have these six countries, facing similar pressures to reform their health care systems, with similar options for government action, chosen very different pathways to restructure their health care? What did they do? And what happened after the implementation of those reforms? The article describes the current arrangements for funding, contracting and payment, ownership and administration (or “governance”) of health care at the beginning of the twenty-first century, the origins of the health care reforms, the discussion and choice of policy options, processes of implementation and “after reform adjustments”. The article looks at factors that help explain the variety in reform paths, such as national politics, dominant cultural orientations and the positions of major stakeholders.

Learning and mislearning across borders: what can we (not) learn from the 2006 health care reform in the Netherlands? Commentary on Rosenau and Lako.

In the last two years, several newspapers and academic journals have paid attention to the new Dutch health insurance reform of 2006 that replaced the former public and social health insurance schemes (see, e.g., Enthoven 2008; Enthoven and Van de Ven 2007; Harris 2008; Naik 2007; Rosenau and Lako, this volume). Some commentators enthusiastically embraced the Dutch model as the solution for the United States (Naik 2007; Van de Ven and Schut 2008). “The implementation of a Dutch model in the US could extend its best practices to the whole population,” argue Enthoven and Van de Ven (2008: 2421). In itself, it is a good thing that the discussion on the future of our health care systems has widened to experiences abroad. But the reports of recent policy changes in Holland illustrate the difficulty of providing an accurate picture of the changes in another country. It is too soon to tell whether the reforms will work as expected or intended, and we should avoid rushing to judgment or foolishly claiming that the Netherlands offers a magical answer for the United States. As we watch what happens, and as we think about lessons for the United States or other countries, we should keep in mind four common mistakes often made by those who write about cross-national politics: factual errors, misleading labels, failure to take context into account, and failure to look at actual implementation. Much of the commentary reveals inaccurate descriptions, ignored underlying policy assumptions, and overgeneralized conclusions. That should warn

Six countries, six reform models : the healthcare reform : experience of Israel, the Netherlands, New Zealand, Singapore, Switzerland and Taiwan : healthcare reforms "under the radar screen"

Health Reform in Chile: From Military to Democratic Governance Health Reform in Israel: Partial Policy Implementation as Learning Opportunity Health Reform in The Netherlands: Change and Continuity Health Reform in New Zealand: Reform and Re-form Health Reform in Singapore: Willingness to Change and Pragmatism Health Reform in Switzerland: Privatizationj, Decentralization and Constraints of Federalism Health Reforms in Taiwan: Learning from International Experience and National Adjustments Conclusions: What to Make of the Reform Experiences? Empirical and Theoretical Findings.

Beyond Euro-centrism: health care reforms of seven small countries

The economic, ideological and demographic pressures in the aftermath of the 1973–74 oil crises led to the reassessment of welfare states. Policy-makers looked across borders for solutions to national problems. That fueled the rapid growth of cross-national studies, most of which were descriptive and lacked well-defined core concepts. Widely used terms like health reform, managed competition or consumer-driven health care are rarely defined in any operational way. Often, policy as stated in government documents or law differs from policies implemented. Health care reform should be defined as major shifts in both decision-making power and financial risks in the funding, contracting, ownership and administration of health care. Decision-making power and financial risks can shift from national to regional and local governments or from governments to insurers, patients and the insured (as well as in opposite directions). We can learn a lot from looking at countries that are not usually included in international comparisons. Chile, Israel, the Netherlands, New Zealand, Singapore, Switzerland and Taiwan not only discussed major reform during the last decades of the twentieth century, but actually implemented changes. At first sight those countries differ from one another in many ways: geographical location, population size, ethnic composition, history and styles of policy-making. However, they share the policy goal of providing universal access to health care while restraining public expenditure. Facing similar financial constraints, growing (and changing) demand for health care, and changing views of the role of the state, all seven considered a similar range of reform options. In the end, however, their reforms were strikingly different. What explains that divergence? What happened after implementation? Switzerland (in 1995) and Holland (2006) introduced ‘consumer-driven health insurance’. Legal residents have to take out individual health insurance. In both countries, the system is less market-oriented than some experts claim or some foreign observers seem to hope. In both countries, after the first year, only a few citizens opted to switch insurer, and health costs and premiums went up considerably after the introduction of the insurance mandates. The Chilean experience illustrates that a change in political regime can create the opportunity for change. But dominant values as well as long-standing institutions restrain policy change. The military Pinochet regime (1973–1990) encouraged private health insurance to reduce public spending, but it did not dismantle all public services. Likewise, the restoration of democracy in 1991 did not do away with private health insurance but instead expanded public spending to improve the quality of public services and imposed extensive regulation on private insurers. Israel has been successful in depoliticizing decisions over entitlements. After expanding employment-based insurance to cover the entire population, it set up an independent expert committee to approve new entitlements each year, within budget limits set by the treasury. New Zealand engaged in market-oriented economic reforms after the depression of the 1980s. A shift to a conservative government a few years later prompted reshaping of the health care system. Likewise, the changed electoral system (that led to coalition governments and thus more consensual policy-making), mounting dissatisfaction both about poor results from the reforms and about the notion of markets in health care, and a return of a labour government to power in 2000 created an opportunity to undo some of the market reforms and shift to a much stronger public orientation. Singapore’s long-ruling People’s Action Party (in power since 1959) was able to pursue its reform agenda without much opposition. One interesting and generally poorly understood element of the funding of Singapore’s health care are the medical savings accounts (sometimes touted as consumer-driven health care). Families can pay their medical bills (and premiums) out of their accounts. In times of budget surpluses, government adds to the schemes of low-income families. In 2006, health expenditure was about US

Health Care Systems in Transition: An International Perspective (review)

5 billion. Remarkably, most savings are left in the savings accounts which had amassed over US

Population Aging and the Sustainability of the Welfare State

24 billion but only funded about 10% of expenditure (government subsidy, employer contributions, user fees and private insurance fund the other 90%). Taiwan’s ‘window of opportunity’ included favourable economic conditions, rising popular demand for universal coverage, mounting opposition against the ruling nationalist party, and the strong personal leadership of then President Lee Teng-Hui. Based on extensive studies of experience abroad, government bureaucrats and scholars implemented social health insurance in 1995, rejecting notions of market competition. The rapid implementation created some

Managed Competition for Medicare? Sobering Lessons from the Netherlands

The last decade of the twentieth century witnessed a rapid growth in the number of comparative studies in the area of health care. There are different categories that range from aggregate statistical studies, broadbased descriptive comparisons, and analytical studies focused on specific policy topics in a limited number of countries, to studies that apply an elaborate theoretical framework based on individual country health care studies. A list of references at the end of this review gives examples of each group. The book Health Care Systems in Transition, edited by Francis D. Powell and Albert F. Wessen, belongs to the third category of comparative studies: it seeks to draw lessons (for U.S. policy makers and others) from the experience in four OECD countries—the United Kingdom, Germany, Sweden, and Canada. The central question of the book is, What structural adjustments do national health care systems seek to implement in reaction to the new and challenging conditions of changing economic, political, and social circumstances (ix)? In the three final chapters, the editors try to answer this question in different ways. Wessen (chapter 16) compares the way countries reacted to common issues of demand pressure, aging, technological innovation, and social change. He considers the factors that have contributed to success in cost control: the possibility of imposing global budgets, changes in payment structures, and controls on capital spending. The impact of neoclassical economic thinking affected health policies in the United Kingdom, Germany, and Sweden but hardly in Canada. Wessen points to resulting changes in the pattern of medical care, such as an increased emphasis on prevention, primary care, and long-term care for the elderly and chronically ill, and increased monitoring of medical practice. In most cases, the principal motor driving the changes has been the need for cost control, but there has been more rhetoric than reality in the shift toward market allocation in health care. No country wants to compromise the principles of universal access and solidarity. Most reforms entailed fiscal and administrative measures such as the introduction of global budgets, changes in payment methods, and restrictions on medical education and medical practice. Wessen concludes “We have sought to associate variations in the process of health system change with structural differences . . . [but] the patterns of reform seem not to be clearly differ1178 Journal of Health Politics, Policy and Law

Comparative Studies and the Politics of Modern Medical Care

Many older people need external support for their daily living. A large minority of older adults with low or modest pension incomes face financial strains from the high cost of illness, and many older people in urban areas live in social isolation. Indeed, population aging has become a policy topic of concern. The policy debate since the end of the twentieth century about the future of public pensions and health and long-term care programs has increasingly framed the growing numbers of older people in alarmist terms. Unfounded claims about the unaffordability and unsustainability of social policies supporting older people have become common currency, often disguised as concerns about intergenerational justice. Such claims and concerns hinder clear thinking about proper social and fiscal policies, housing, health care, and labor markets to safeguard the well-being of older people in aging societies.