Why Health Care Reform Now? Strategic Framing and the Passage of Obamacare

Economic reform and health care reform were both focal points outlined in President Obama's policy agenda, with increasing pressure to address economic and social insecurity given that President Obama entered office during the Great Recession (2007–09). The Patient Protection and Affordable Care Act (commonly known as ‘Obamacare’) successfully passed in March 2010 in the context of the economic crisis. We argue that the strategic framing of the economic crisis, through reasoning and arguments linking health care reform with economic downfall, is important in understanding the successful passage of Obamacare, and that this is reflected through strategic frames in speeches delivered by the President on health care reform. Health care reform has been successful not in spite of but rather because of the economic crisis of 2008, that allowed President Obama to use a strategic frame focusing on costs and economic problems. The two main frames identified are the ‘market’ and ‘rights’ frames. President Obama's strategic frames specifically surrounding the economic and cost‐containment priority of health care reform are categorized as a ‘market’ frame in this article. He used this frame until the passage of the law in 2010, when the frame shifted to ‘rights’ frames, largely portrayed through anecdotes and focused on the concept of ‘access’ to care rather than the ‘cost’ of care. This is observable through tracking speeches and statements made in support of health care reform between 2009 and 2013.     

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.     

Informing Debate or Fuelling Dispute? Media Communication of Reconfiguration in Scotland's Rural Maternity Care

Public reaction to the UK's ongoing health sector reform often results in dilution of policy‐makers’ goals. Public participation in health service decision‐making is advocated in policy, but precisely how to do it and what role public opinion should have in formulating reform strategy is ambiguously described. Public opinion is formed through many influences, including media reporting. This paper examines how reconfiguration at a rural maternity unit at Caithness General Hospital in Wick, Scotland, was communicated in national and local media and considers potential implications of media communication on public participation in policy decision‐making. Content analysis of arguments for and against change revealed a high level of reporting of commentators against change in regional newspapers. Qualitative analysis identified emergent themes about how maternity service reconfiguration was portrayed. These included framing opposition between management and local people, and change drivers receiving superficial coverage. Findings suggest that media portrayal of the public role in change may promote an adversarial rather than a participative stance. More finely tuned understanding of the relationship between the reporting of change and public reaction should be attained as this could affect how planned social policy evolves into actual practice.     

Portuguese healthcare reforms in the context of crisis: External pressure or domestic choice?

As a result of the recent economic crisis, in 2011, Portugal signed a Memorandum of Understanding with the European Central Bank, the European Commission, and the International Monetary Fund (the “Troika”). In exchange for Troika's financial assistance, the Memorandum required the implementation of a specific set of reforms targeted at the healthcare sector. The literature on policy reforms in the context of crisis and conditionality argues that governments have restricted room to manoeuver in responding to external pressure. We challenge this view, finding that even in cases of conditionality and strong external pressures, crisis can be used as a window of opportunity for reforms substantially shaped by domestic policy choices. In the case of Portuguese health reforms, these choices were based on pre‐existing reform plans aimed on resolving country‐specific deficiencies of the healthcare system and were enabled by the two main political parties' strategies of tacit cooperation and blame avoidance. The article emphasizes the need for more fine‐grained analysis of welfare reforms in the crisis that pays equal attention to the institutional characteristics and the political context of the affected countries.     

Advocacy coalitions and policy change on nuclear power utilization in Taiwan

Before the mid-1980s, the development of nuclear power was regarded as essential to facilitate Taiwan's rapid economic growth. Since 1980s, the feasibility of utilizing nuclear power has been intensively challenged. The policy impact of rise of the anti-nuclear movement and environmental movement in conjunction with democratizing trends is especially evident in the controversy over constructing the Fourth nuclear power plant in Taiwan. Ongoing construction of the plant was halted after the anti-nuclear presidential candidate won in Taiwan's 2000 presidential election. However, the decision to scrap the project was abandoned and the project was resumed in less than four months. This article applies the Advocacy Coalition Framework (ACF) to explain and analyze the development of advocacy coalition and policy change on nuclear power utilization in Taiwan. Based on this study, it is argued that the ACF could be more useful for comparative applications if it takes both political context and international influences into account.     

‘Southern‐style’ National Health Services? Recent Reforms and Trends in Spain and Greece

This article analyses recent changes in the Greek and Spanish national health services. The aim is to assess how the period of austerity and further recovery during the 1990s and early 2000s impacted on them in terms of equity and efficiency. This is of interest because of the closeness in time between the universalizing reform laws and the arrival of the conditions for economic convergence established in the Maastricht Treaty. The analysis is also attractive because it deals with the transformation of already mature health insurance systems into national health services, a transformation that is novel in European welfare history. The article addresses the questions of whether austerity has hindered full implementation of the reform laws enacted in the early to mid‐1980s, examining reform trajectories and financing and expenditure trends. Furthermore, it considers the impact on access, understood in terms of population coverage, the array of services provided, waiting lists, and territorial inequalities. Finally, it discusses the introduction of new managerial formulas and attempts at enhancing efficiency. The concluding section states that divergent trajectories have occurred, thus rendering the definition of a ‘Southern model of health care’ difficult. It also provides explanations of the trajectories followed in both national cases and informs on prospects for the future.     

Unravelling the Politics of Activation Reforms: Exploring the Unusual Israeli Trajectory

Contemporary active labour market (ALM) reforms are pivotal in the reorganization of the welfare state as they challenge and threaten some of the fundamental achievements of labour in capitalist societies: social programmes and entitlements that compensate for unemployment, and governance arrangements in which the social partners share authority and responsibility with the state. Consequently, ALM reforms may give raise to social unrest and political struggle that involves the state (the main proponent of ALM reforms), trade unions and political parties. These conflicts are important in the politicization of reforms, i.e. raising public awareness of and engagement with controversies of welfare state change. In this article, we use a non‐European perspective to ask more generally how distinct historical institutions create separate ‘politicization trajectories’ of ALM reforms, which in turn produce different policy designs and outcomes. Centring on the case of Israel, in which historically ‘abnormal’ class politics fostered indifference to the reform in both trade unions and political parties, we maintain that the preliminary de‐politicization made it possible for bureaucrats to control the reform, leading to an intra‐state conflict between competing agencies over its design and implementation. The usurpation of the reform by the Ministry of Finance made it conspicuously unbalanced, provoking many grievances. Paradoxically, the de‐politicization of the reform advanced its re‐politicization, led by non‐governmental advocacy organizations in civil society. These uncommon political actors in the politics of ALM reforms were able to lead a counter‐coalition, delegitimize the reform, and mobilize politicians to eventually terminate activation     

How much do OECD countries spend on social protection and how redistributive are their tax/benefit systems?

The global economic crisis has reignited interest in social policy and public spending on different types of social benefits. Public social spending‐to‐GDP ratios are often used to consider the magnitude of welfare systems in international perspective, but such comparisons alone give an incomplete picture of social effort across countries. This article looks at these different factors, before briefly considering the redistributive nature of tax/benefit systems in different member countries of the Organisation for Economic Co‐operation and Development (OECD). The article also considers trends in social spending and compares spending in the late 2000s with the early 1990s when the previous economic crisis played out. The article ends by illustrating the profound effect the recent global economic crisis had on social spending trends across OECD countries.     

Healthcare in India: Changing the Financing Strategy

The way in which healthcare is financed is critical for equity in access to healthcare. At present the proportion of public resources committed to healthcare in India is one of the lowest in the world, with less than one‐fifth of health expenditure being publicly financed. India has large‐scale poverty and yet the main source of financing healthcare is out‐of‐pocket expenditure. This is a cause of the huge inequities we see in access to healthcare. The article argues for strengthening public investment and expenditure in the health sector and suggests possible options for doing this. It also calls for a reform of the existing healthcare system by restructuring it to create a universal access mechanism which also factors in the private health sector. The article concludes that it is important to over‐emphasize the fact that health is a public or social good and so cannot be left to the vagaries of the market.     

Explaining Different Paths in Social Health Insurance Countries – Health System Change and Cross‐border Lesson‐drawing between Germany,Austria and the Netherlands

The issues of ‘policy diffusion’ or ‘policy transfer’ and ‘mutual learning’ have become important topics in comparative research on social policy and health systems. In current debates on explaining reform in ‘Bismarckian’ social (health) insurance systems, however, these issues have been neglected. In particular, the role of ‘negative lesson‐drawing’ in the sense of avoiding mistakes of others has not often been considered. This article compares health system change in Germany, Austria and the Netherlands, three countries with health systems of the social insurance type. In contrast to the existing literature, our analysis stresses that these countries have taken different reform paths since the 1990s. By applying a most similar systems design, we analyze how far cross‐border lesson‐drawing has contributed to health system divergence in the three countries. The empirical basis of the analysis is semi‐structured qualitative expert interviews, a method appropriate for tracing processes of lesson‐drawing. We argue that in order to fully understand the diverging reform trajectories, we need to take into account how political decision‐makers refer to (negative) experiences of other countries. Generally, national driving forces for health system change were at the heart of many crucial reforms during the period studied. Nevertheless, we claim that it was the German bad practice role model that kept the reform paths of Austria and Germany apart in the Austrian health reform discussion between 2000 and 2005.     

Human Motivation and Professional Practice: of Knights, Knaves and Social Workers

Efforts to improve the efficiency and responsiveness of public services by harnessing the self‐interest of professionals in state agencies have been widely debated in the recent literature on welfare state reform. In the context of social services, one way in which British policy‐makers have sought to effect such changes has been through the “new community care” of the 1990 NHS and Community Care Act. Key to this is the concept of care management, in which the identification of needs and the provision of services are separated, purportedly with a view to improving advocacy, choice and quality for service users. This paper uses data from a wide‐ranging qualitative study of access to social care for older people to examine the success of the policy in these terms, with specific reference to its attempts to harness the rational self‐interest of professionals. While care management removes one potential conflict of interests by separating commissioning and provision, the responsibility of social care professionals to comply with organizational priorities conflicts with their role of advocacy for their clients, a tension rendered all the more problematic by the perceived inadequacy of funding. Moreover, the bureaucracy of the care management process itself further negates the approach's supposedly client‐centred ethos.     

Social Policy in Greece: Rhetoric versus Reform

This paper reviews the major social policy developments in Greece during the 1980s and 1990s, focusing on social security, health and employment policies. It argues that the concept of social policy and the practice of politics have been distorted in this country. Social policy reflects the legacy of a heavily politicized and centralized policy‐making system, an impoverished administrative infrastructure and poorly developed social services. Its emergence is characterized by the pursuit of late and ineffective policies. It lacks continuity, planning and coordination, being oriented towards short‐term political expediency. It is largely insurance‐based, reproducing huge inequalities and institutional arrangements which are behind the times. It provides mainly cash benefits, low‐quality but rather expensive health services and marginal social welfare protection. Moreover, the lack of a minimum income safety net confirms the country's weak culture of universalism and social citizenship. By implication, complex policy and interlocking interest linkages have tarnished the “system” with a reputation for strong resistance to progressive change. At the same time, sources of change such as globalization, demographic developments, new household and family/gender patterns, unstable economic growth, fiscal imperatives, programme maturation, as well as persisting unemployment, changing labour markets and rising health care costs, have produced mounting pressures for welfare reform.     

Citizens' attitudes towards economic insecurity and government after the 2007 financial tsunami: A Hong Kong and Taiwan comparison

Wang KY‐T, Wong C‐k, Tang K‐L. Citizens' attitudes towards economic insecurity and government after the 2007 financial tsunami: A Hong Kong and Taiwan comparison The purpose of this study was to investigate people's attitudes to economic insecurity and government in Hong Kong and Taiwan after the financial tsunami of 2007. Random sampling telephone surveys were conducted in July 2009. These are the main conclusions: First, the most vulnerable groups hurt by the financial crisis were low‐income families and people who had lost their job or were afraid of losing it. This implies that the old policy issue of social stratification and the emerging policy issue of employment insecurity coexisted during the financial crisis. Second, personal experiences of economic insecurity had an influence on people's perceptions of the severity of the economic crisis at the societal level. Third, citizens had ambivalent feelings about public interventions during the crisis. Fourth, there were both convergence and divergence between Hong Kong and Taiwan with regard to attitudes to particular issues. The policy implications of these findings are discussed in the final section of this article.     

The Ageing of Australia: Fiscal Sustainability,Intergenerational Equity and Inter‐temporal Fiscal Balance

Australian public policy makers are presently confronted with significant demographic changes that will profoundly affect the formulation of rational economic and social policy over the long term. This paper seeks to outline the potential impact of this demographic change and place it in historical perspective. The challenges posed by an ageing population for fiscal policy are explored and it is stressed that policy inertia will invite severe costs in future. It is argued that an appropriate policy stance should be developed in the context of a framework for inter‐temporal fiscal balance not only to focus on long‐run fiscal sustainability, but also to include considerations of intergenerational equity.     

When Social Health Insurance Goes Wrong: Lessons from Argentina and Mexico

Social health insurance (SHI) has gained popularity in recent years as a health‐care funding mechanism for developing countries in Latin America and beyond. This is reflected in a number of high‐profile conferences sponsored by international agencies, and a profusion of externally funded reform projects. This article assesses the potential of SHI to provide a sound model of health‐care financing, drawing on the experiences of Argentina and Mexico. It uses four criteria to assess the performance of SHI: coverage, equity, effectiveness and sustainability. The article begins by outlining key principles of SHI and comparing it to other models of health‐care financing. It then gives a comparative overview of four SHI programmes in Argentina and Mexico, before analysing their performance in greater detail. The article finishes by extracting lessons from this comparative analysis, both for the countries studied and for global debates on SHI.     

Anti‐Poverty Family Policies in China: A Critical Evaluation

Despite its rapid economic growth, China remains a developing country facing serious challenges of poverty and inequality. This article examines the development and effectiveness of China's primary anti‐poverty family policy, the Minimum Living Standard Assurance (MLSA, or Dibao). Using rich administrative data and building on the existing literature, this article provides a critical evaluation of MLSA's benefit generosity, coverage, targeting, and anti‐poverty effectiveness. To help reinforce MLSA's anti‐poverty impacts, local governments in recent years have implemented a series of supplementary policies and programs, including health, education, housing, and work support programs. This article also provides an assessment of these supplementary policies and programs and draws policy implications for the ongoing expansion of the Chinese government's anti‐poverty efforts.     

The Use of Group Work to Fight Acute External Threats to a Community-Based Organization During Harsh Economic Times

This article addresses the use of group work in a community-based outpatient children's mental health agency to respond to financial threats by county and state government during the economic downturn of 2008–2009. Three specific threats that came within months of one another are discussed: (1) the threat to close down a chemical dependency treatment service for youth, (2) severe funding cuts to an outreach program for immigrant youth and their families, and (3) a state government plan to restructure/reform reimbursement for outpatient mental health services that promises to reduce access to care for underinsured families. Group work was used to organize, educate, and activate staff, board, community, and consumer groups, in large and small groups, to counter the threats and build a culture of advocacy. Lending a vision, empowering advocates, managing polarity, and shaping the advocacy message were essential elements of the advocacy process.     

‘A Common Sense of the Times’? Neo‐liberalism and Changing Public Opinion in New Zealand and the UK

Neo‐liberalism represents a significant and enduring shift in the politics shaping social policy. Although frequently ascribed a hegemonic, all‐powerful status that focuses our attention on the coherence found in neo‐liberal policies, this article builds on scholarly work highlighting variegation in the neo‐liberal project across different policy areas, national settings and time periods. Specifically, it employs Peck's and Tickell's (2002) view that neo‐liberalism has gone through multiple phases in response to both external and internal crises as an entry point for studying neo‐liberalism's impact on public support for the welfare state. Drawing upon New Zealand and British attitudinal data, the article argues that public reactions to an early period of retrenchment (‘roll‐back’ neo‐liberalism) differ from those reported in the ‘roll‐out’ or embedding phase of neo‐liberalism implemented by Third Way Labour Governments in both countries. Indeed, continuing public support in many policy areas arguably contributed to the internal crisis that provoked an adaptation to the neo‐liberal project. The article further explores public support for the welfare state following the external crisis provoked by the financial meltdown of 2008–09 asking whether New Zealand and British attitudes showed signs of resisting austerity measures or whether they, instead, indicated a third, ‘roll‐over’ period of neo‐liberalism where the public accepted not only a neo‐liberal economic agenda but also the need for further retrenchment of the welfare state. Conclusions about the politics of social policy at the level of public opinion offer both good and bad news for welfare state advocates.     

The Reform of Health Policy in China – Left Behind in the Race to Industrialize?

A major programme of health reform was announced in 2009. China is growing fast, and is beginning to engage with the international social policy community to discuss and review the consequences of rapid industrialization. As a specific part of social policy, health policy shares some of the characteristics of a policy area driven by the consequences of industrialization, but it also has its own particular features. This article reviews the general relationship between state and citizens in the health field by way of an introduction before focussing more specifically on Chinese patterns of health inequalities, and the pressures for reform. The 2009 reform of health policy and its dynamics are then presented, and the article concludes that there has been a deterioration in Chinese health policy, which threatens to undermine the benefits of economic growth for Chinese people.