Towards Neo-Bismarckian Health Care States? Comparing Health Insurance Reforms in Bismarckian Welfare Systems

Germany, France and the Netherlands all have specific ‘Bismarckian’ health insurance systems, which encounter different and specific problems (and solutions) from those of national health systems. Following a relatively similar trajectory, the three systems have gone through important changes: they now combine universalization through the state and marketization based on regulated competition; they associate more state control (directly or through agencies) and more competition and market mechanisms. Competition between insurers has gained importance in Germany and the Netherlands and the state is reinforcing its controlling capacities in France and Germany. Up to now, continental health insurance systems have remained, however, Bismarckian (they are still mainly financed by social contribution, managed by health insurance funds, they deliver public and private health care, and freedom is still higher than in national health systems), but a new ‘regulatory health care state’ is emerging. Those changes are embedded in the existing institutions since the aim of the reforms is more to change the logic of institutions than to change the institutions themselves. Hence, structural changes occur without revolution in the system.     

Introducing social insurance for long‐term care in Taiwan: Key issues

Nadash P, Shih Y.‐C. Introducing social insurance for long‐term care in Taiwan: Key issues Taiwan will shortly complete its comprehensive social safety net, which includes national health insurance, retirement security, and unemployment insurance, by introducing long‐term care (LTC) insurance – putting it ahead of the many countries that rely on a patchwork of policies to address the need for LTC. The program, to be implemented in 3 to 5 years, will cover all citizens on a primarily social insurance basis. The range of LTC policy options considered is discussed, particularly how to structure the program, how to finance and regulate it, and how to develop its inadequate LTC infrastructure and workforce. Particularly thorny issues include the choice of social insurance, the feasibility of cash benefits, and how to address Taiwan's heavy reliance on foreign workers. Taiwan's increasingly democratic character, along with high levels of public support for the program, creates significant pressure on politicians to deliver on their promises to implement LTC reform. Key Practitioner Message: ?Emphasizes the importance of policy learning from other environments; ?Highlights the need for a strong regulatory and provider infrastructure for delivering long‐term care services; ?Emphasizes the need for training, support, and appropriate regulation of the long‐term care workforce.     

Garbage‐can Policy‐making Meets Neo‐liberal Ideology: Twenty Five Years of Redundant Reform of the English National Health Service

The garbage‐can theory of decision‐making (Cohen et al. 1972), has been adapted into a perspective on policy‐making, with adaptations of the approach placing notable emphasis upon the health sector (Kingdon 2006; Paton 2006). This article creates an adapted ‘garbage‐can’ framework to help explain each stage of the reform of the English National Health Service (NHS) over the last 25 years. The emergence of the key idea and resultant policy at each stage of reform of the English NHS has been arational and indeed sometimes irrational. Policy has reflected advocacy by policy‐salesmen (Kingdon 2002), proffering ‘solutions’ to ill‐defined problems and answers to unasked questions, and politicians' short‐termist responses at each decision‐point. Yet the garbage‐can alone is not enough: if arationality rules in policy‐making day to day, this does not mean that there is not an overall ideological context, trend or bias in reform. The article also posits that ‘market reform’ has derived from the ideological hegemony of a naive anti‐statism (hostility to a misleadingly defined and often mythological ‘centralist state’) in public services and enthusiasm for market competition rather than any evidence‐based application of pro‐market ideas to health policy. A question arises: how are these two approaches (short‐term arationality and longer‐term ideological bias) combined in explanation of how policy over time is biased in a particular direction while seemingly arbitrary and directionless at each messy decision‐point. The article attempts to combine the insights of a garbage‐can approach with wider explanations of ideological hegemony.     

The Fiscal Crisis of National Health Insurance in the Republic of Korea: In Search of a New Paradigm

In 2001, National Health Insurance (NHI) in Korea, the social insurance system for health care with universal population coverage, experienced a serious fiscal crisis as its accumulated surplus was depleted. This fiscal crisis is attributed to its chronic imbalance: health care expenditure has increased more rapidly than have insurance contributions. The recent failure in implementing pharmaceutical reform was a further blow to the deteriorating fiscal status of the NHI. Although the NHI has since recovered from the immediate fiscal crisis, this has mainly been because of a temporary increase in government subsidy into the NHI. The strong influence of the medical profession in health policy‐making remains a major barrier to the introduction of policy changes, such as a reform of the payment system to strengthen the fiscal foundations of the NHI. Korea also has to restructure its national health insurance in an era of very rapid population ageing. A new paradigm is called for in the governance of the NHI: to empower groups of consumers and payers in the policy and major decision‐making process of the NHI. The fiscal crisis in Korean national health insurance sheds light on the vulnerability of the social health insurance system to financial instability, the crucial role of provider payment schemes in health cost containment, the importance of governance in health policy, and the unintended burdens of health care reform on health care financing systems.     

Health Care in Asia and the Pacific: Increasing the focus on social health insurance

This paper focuses on health insurance reform within the broader frameworks of both social security and health services system development. In most countries in Asia and the Pacific, it is indeed the reform of the health services system, through policy changes in health care financing, that has led to an increased focus on health insurance. The underlying issue in this reform is the shift in responsibility that has taken place in most countries in the region over recent years. In the past, governments were responsible for financing health care for their populations. This shifted to defining, legislating and implementing an appropriate health care financing mechanism, presenting several challenges: to reach universal health insurance coverage through new initiatives for new populations, mainly the informal sector accounting for the majority of the population in almost all these countries; to apply provider payment systems that enable control over costs and the volume of utilization; and to strengthen primary health care as a foundation for rational utilization and more resources for prevention, including prevention of chronic diseases among the ageing population. This approach will require an active partnership between health insurance schemes and government that should reflect the new division of responsibilities to guarantee access to high-quality health care for all.     

Divergence in the development of public health insurance in Japan and the Republic of Korea: A multiple‐payer versus a single‐payer system

Japan and the Republic of Korea achieved universal health insurance coverage for their populations in 1961 and 1989, respectively. At present, Japan continues to operate a multiple‐payer social health insurance system, while the Republic of Korea has moved to an integrated single‐payer national health insurance structure. This article analyzes the influence of political economy in shaping the policy divergence found between these two Bismarckian health insurance systems. Issues addressed include differences in political power, the policy influence of business, the extent to which regional autonomy has developed and regional traits have been preserved, the level of political democratization, the form of political leadership, and the scale of development of the health insurance system. The article offers policy lessons derived from the two countries' experiences.     

The Swiss social insurance system: Social security and grass‐roots democracy

The foundations of Switzerland's social insurance system can be traced to 1890 when a public referendum voted the inclusion of an article into the Federal Constitution that gave the executive the task of creating a sickness and accident insurance scheme. Currently, as in other European countries, the Swiss social insurance system is facing challenges as a result of rising health costs and demographic shifts, which are placing a growing burden on both public finances and private households. To reach policy decisions to address these challenges, the Swiss system is distinguishable from those of its European neighbours because of a continuing tradition of political decision‐making based on grass‐roots democracy: through referenda, the Swiss people remain directly responsible for the development of the national social insurance system. Importantly, not only might this unique feature of Swiss democracy lead the Swiss people more readily to accept and identify with their social insurance system but it may offer a sound democratic base upon which to build a consensual approach to address the policy challenges that lie ahead.     

Multi‐pillared social insurance systems: The post‐reform picture in Chile,Uruguay and Brazil

This article focuses on an analysis of social insurance models and reforms in Chile, Uruguay and Brazil. Noting that these three countries are following different reform trajectories, the article explores trends in the restructuring of each of these insurance systems across the course of successive reforms. In the systems, different trends are supporting a closer link between contributions and benefits, according growing importance to private individual accounts and favouring the expansion of the role played by social assistance. These trends all suggest a move towards various forms of multi‐pillared social insurance, but with uncertain results in terms of redistribution and the dynamics of the fundamental objectives of social insurance.     

Health Policy in the Asian NIEs

This paper compares the health policies of Hong Kong, South Korea, Singapore and Taiwan with the purpose of drawing policy lessons. The study finds two distinct policy clusters: Hong Kong and Singapore on the one hand, and Korea and Taiwan on the other. With respect to provision of health care, the former rely largely on public hospitals for delivering inpatient care while the latter rely on private hospitals. In matters of financing, they are similar in that out‐of‐pocket is a major source of financing in all four countries. However, they are also different because Korea and Taiwan have universal health insurance while the city states do not. The study concludes that public provision of hospital care, as in Hong Kong and Singapore, yields more favourable outcomes than many mainstream economists would have us believe. Conversely, private provision in combination with social insurance, as found in Korea and Taiwan, severely undermines efforts to contain health care costs.     

Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage

Mongolia achieved high population coverage under mandatory health insurance relatively quickly. This fact was viewed by policy‐ and decision‐makers as a central issue for health financing reform in Mongolia. Health insurance brought many new features for health service planning, provision, funding and resource management. Based on initial achievements, health insurance came to be strategically considered as the vehicle for achieving universal coverage. The article analyses developments in Mongolia's health insurance over the last decade along with the core policy dimensions of Universal Health Coverage. It examines various reform approaches and the numerous amendments to laws that have been implemented during this period and discusses new opportunities as well as challenges. The analytical review and findings discussed suggest that Mongolia has a need for evidence‐based policy decisions and informed political support, with health insurance backed by robust institutional and administrative capacities. More generally, it also emphasizes that health policy goals and objectives can be attained by strengthening and making transparent and publicly‐accountable all health system financing functions and arrangements. The policy analysis, experiences, lessons and proposed strategies presented with regard to Mongolia intend to stimulate wider discussions on health insurance development as well as promote continuing focused research on specific aspects of health insurance and public financing reform.     

Obamacare and the Politics of Universal Health Insurance Coverage in the United States

In the USA, universal coverage has long been a key objective of liberal reformers. Yet, despite the enactment of the Patient Protection and Affordable Care Act (PPACA) (commonly known as ‘Obamacare’) in 2010, the USA is not set to provide health care coverage to all, even if and when that reform is fully implemented. This article explores this issue by asking the following question: Why was a clear commitment to universal coverage, the norm in other industrialized countries, excluded as a core objective of the PPACA and how has post‐enactment politics at both the federal and the state level further shaped coverage issues? The analysis traces the issue of universal coverage prior to the debate over the PPACA, during the 2008 presidential race, and during consideration of the bill. The article then looks at the post‐enactment politics of coverage, with a particular focus on how states have responded to the planned use of the Medicaid programme to expand access to care. The article concludes by discussing how an explanation of the limits of the PPACA, in terms of both its commitment to universal coverage and, more importantly, the failure to provide comprehensive health insurance to all, requires an understanding of complex institutional and policy dynamics.     

The Politics of Social Policy Language

A number of scholars have recently shown that key social policy concepts like ‘welfare state’ are both vague and problematic. Drawing on the international literature on the role of ideas in social policy, this article compares the development of two major policy concepts in two countries where the language of social policy is openly contentious: the USA and France. Focusing on the last three decades, the article discusses the meaning and development of the concepts of ‘social security’/‘sécurité sociale’ and ‘welfare state’/‘État‐providence’ in both countries. As suggested, these two concepts have long been controversial, in part because they are typically involved in the inherently political drawing and redrawing of the contested boundaries of state action. Overall, the article explains how the comparative analysis of social policy language can help scholars adopt a more reflexive approach.     

Tackling and Mitigating Health Inequalities – Policymakers and Practitioners ‘Talk and Draw’ their Theories

In the context of a long‐standing academic acceptance of the socially structured nature of health inequalities, there has been a growing literature that critically examines policies that aim to reduce them. This has demonstrated inadequate policy assessment of the nature of the problem of health inequalities and correspondingly partial solutions that privilege interventions that focus on individual lifestyle solutions over more structural approaches. Much of the research that has been undertaken in this field to explore competing theories of inequalities has analyzed national policy documents or the views of senior policy advisers rather than practitioners. This study uses Raphael’s ‘seven discourses of the social determinants of health’ to understand the implicit theories of health inequalities of both practitioners and policymakers working within a single health care system as they talk about different policy typologies. To help penetrate potentially well‐rehearsed discourses about health inequalities, it tests a visual method of stimulating discussion about how different types of policy might operate to narrow/widen existing gaps in outcomes. Building on Raphael, it finds that individuals’ theories of health inequalities contain co‐existing although not synthesized material and behavioural explanations and that, although the social patterning of material disadvantage was recognized, the role of power and politics is underplayed. Variations between participants did not align with role (policy/practice) and using visual methods to represent the impact of different policy types on health inequalities, though challenging for participants, stimulated reflection about a subject matter that has otherwise become rather stagnant.     

Cash‐for‐care policy in Sweden: An appraisal of its consequences on female employment

In 2008, Sweden introduced a cash‐for‐care benefit consisting of a flat‐rate sum paid by municipalities to parents whose children were between the ages of one and three and who did not use publicly subsidised childcare. The main object of the reform was to increase parents’ ‘freedom to choose’, but the policy was criticised because of its potentially negative effects on gender equality and mothers’ employment. This study focuses on the effects of cash‐for‐care on female employment in Sweden. The study shows that the adoption of this policy had negative effects on female employment, although primarily in rural areas. Cash‐for‐care was abolished in Sweden in 2016. To evaluate the effects that the policy had on female employment during the time it was in place is important as it indicates what may happen if the policy is introduced again.     

The Dynamics of Welfare Policy‐Making in South Korea: Social Movements as Policy Entrepreneurs*

This paper analyzes the role of social movements in the creation and evolution of a welfare state in South Korea. We begin with a theoretical overview of the existing works on policy change, highlighting concepts such as ideas, policy paradigms, and windows of opportunity. We then examine state institutions, hegemonic policy paradigms, and the specific dynamics of welfare policy‐making during South Korea’s authoritarian period (1961–1987). Next, characterizing the democratic transition in 1987 and the economic crisis of 1997–1998 as “windows of opportunity,” we probe how social movements emerged as “policy entrepreneurs” and played crucial roles in building welfare institutions and promoting welfare policies. In particular, we focus on the role of social movements in legislating the National Basic Livelihood Security Act in 1999 and consolidating fragmented health insurance systems in 2000. We conclude that social movements in democratized South Korea have assumed the role of policy entrepreneurs, filling the vacuum left by the central government and elite bureaucrats in the field of social welfare policy‐making.     

Activation Reform and Inter‐Agency Co‐operation – Local Consequences of Mixed Modes of Governance in Sweden

Organizational reform has become a recurring solution to problems of social exclusion and unemployment. In Europe, and other parts of the world, there is a trend towards policies of ‘activation’ in employment and social policy. The idea of flexible, individualized and tailor‐made services is coupled with managerial and market‐based reforms as well as collaborative governance. In these complex structures of service provision, coordination and inter‐agency co‐operation have become key concerns. Based on a study of a recent reform of programmes for newly arrived refugees in Sweden (Etableringsreformen), this article seeks to contribute to the literature on governance of ‘activation’ by examining the consequences of mixed modes of governance (market and collaborative) on local inter‐agency co‐operation. Drawing on data from in‐depth case studies in two municipalities, it is demonstrated how the coupling of managerial practices and quasi‐markets with existing collaborative arrangements has created barriers for inter‐agency co‐operation. The results indicate that institutional tensions between governance forms represent an important factor for explaining governance failure in this policy area.     

When Social Partners Unite – Explaining Continuity and Change in Austrian and Dutch Labour Market Governance

Why do Austria and the Netherlands, two highly corporatist, coordinated, consensual countries diverge with respect to the involvement of social partners in their Public Employment Service? By comparing and contrasting the competing predictions of the power‐resource, employer‐centred and social partnership approaches, we identify a key omitted variable that can explain the observed variations: the ability of the social partners to unite on reform positions. We demonstrate that when the social partners are divided, their collective power is reduced and partisan‐based policy outcomes become more pronounced. In turn, when the social partners jointly favour a particular outcome, their collective power increases and they can override governmental reform plans, even if the government holds a large legislative majority. These findings highlight the causal importance of power relations between and within the social partners for institutional continuity and change.     

Parents' involvement in care order decisions: a cross‐country study of front‐line practice

This article examines parents' involvement in care order decision‐making in four countries at one particular point in the care order process, namely, when the child protection worker discusses with the parents his or her considerations regarding child removal. The countries represent different child welfare systems with Norway and Finland categorized as ‘family service systems’ and the USA as a ‘child protection system’, with England somewhere in between. The focus is on whether the forms and intensity of involvement are different in these four countries and whether the system orientation towards family services or child protection influences practice in the social welfare agencies with parents. Involvement is studied in terms of providing information to parents, collecting information from parents and ensuring inclusion in the decision‐making processes. A vignette method is employed in a survey with 768 responses from child protection workers in four countries. The findings do not show a consistent pattern of difference regarding parental involvement in care order preparations that align with the type of child welfare system in which staff work. The goal in each child welfare system is to include parents, but the precise ways in which it is carried out (or not) vary. Methodological suggestions are given for further studies.     

Extension of social insurance coverage to informal economy workers in China: An administrative and institutional perspective

This article reviews administrative issues in the context of decentralized social protection in China. In particular, what are the main obstacles to expanding social insurance coverage for workers in the informal economy? Over the last two decades, China has achieved remarkable progress toward universal social protection when this target was set as a national policy priority. However, the social insurance enrolment of informal economy workers still lags significantly behind. This article reviews the application of the International Labour Organization’s definition of informality in the Chinese context and overviews existing pension and health insurances in China. This article discusses the impact of China’s inter‐governmental fiscal relations and decentralized social protection in the multilevel government system. The article highlights that under a system of decentralized managed social insurance many informal economy workers choose to opt out of the system because of low benefits and high compliance costs. This result in deficits in social insurance coverage amongst informal economy workers.     

Middle‐Class Political Activism and Middle‐Class Advantage in Relation to Public Services: A Realist Synthesis of the Evidence Base

Since the late 1960s social policy scholarship has been concerned with the distribution of the resources or benefits across social gradients. This article presents a review of the literature on one mechanism by which inequity might be produced – activism by middle‐class service‐users enabling them to capture a disproportionate share of resources. The review used the methodology of realist synthesis to bring together evidence from the UK, the USA and Scandinavian countries over the past 30 years. The aim was to construct a ‘middle‐theory’ to understand how and in which contexts collective and individual activity by middle‐class service‐users might produce inequitable resource allocation or rationing decisions that disproportionately benefit middle‐class service‐users. The article identifies four causal theories which nuance the view that it is the ‘sharp elbows’ of the middle‐classes which confer advantage on this group. It shows how advantage accrues via the interplay between service‐users, providers and the broader policy and social context.