Comparative Political Economy of Long‐Term Care for Elderly People: Political Logic of Universalistic Social Care Policy Development

Despite there being common socio‐demographic pressures across advanced industrialized countries, the public elder care programmes therein tend to vary. While the current literature on social care devotes itself to describing the care arrangements of each country and pigeonholing welfare/gender regime types, it does not sufficiently address this empirical puzzle. This study looks to specify the causal relationship between political institutions and public long‐term care programmes. It argues that countries with personal‐vote‐oriented electoral systems and/or fragmented party systems have difficulties in developing universalistic public elder care programmes, whereas countries with party‐vote‐oriented electoral systems and cohesive party systems are likely to develop generous elder care programmes. For whilst the former types of political institutions prioritize patronage‐based, particularistic benefits, the latter types encourage political actors to appeal to broader constituencies through universalistic welfare programmes. This study tests this claim by examining pooled time‐series and cross‐section data of advanced democracies, from 1980 until 2001. The empirical results suggest that politicians' reliance on personal votes and the fragmentation of ruling coalitions impede the expansion of public spending for elder care.     

Public Opinion against Markets? Attitudes towards Market Distribution of Social Services – A Comparison of 17 Countries

This article studies how citizens view the appropriateness of market criteria for allocating services commonly associated with social citizenship rights and welfare state responsibility. The article focuses specifically on a potential role for the market in the provision of social services. The relationship between welfare policy institutions, socio‐economic class and attitudes is explored by comparing attitudes across 17 countries of the Organisation for Economic Co‐operation and Development, using multilevel modelling and data from the 2009 International Social Survey Programme. Results show that public support for market distribution of services is relatively weak in most countries, a result suggesting that public opinion is unlikely to pose a driving force within ongoing processes of welfare marketization. Still, attitudes are found to vary a lot across countries in tandem with between‐country variation in welfare policy design. First, aggregate public support for market distribution of services is stronger in countries with more private spending on services. Second, class differences in attitudes are larger in countries with more extensive state‐led delivery of services. Together, these results point to the operation of normative feedback‐effects flowing from existing welfare policy arrangements. The theoretical arguments and the empirical results presented in this article suggest that future research exploring the relationship between welfare policy and public opinion from a country‐comparative perspective is well advised to place greater focus on the market institutions that, to varying extents in different countries, act as complements to the state in the administration of social welfare.     

Perpetuating the problem: neoliberalism,commonwealth public policy and housing affordability in Australia

This paper argues that the scale of the contemporary housing affordability crisis in Australia is at least partly attributable to the influence of neoliberal ideas over the past three decades. After providing an overview of the nature and scope of the crisis, the process by which housing as a policy problem has been reconceptualised by policy makers and others since the 1970s is examined. This is followed by analysis of the ways in which a number of commonwealth government policies which are ideationally underpinned by neoliberalism have amplified and perpetuated the problem of housing affordability in Australia and, ipso facto, prevented the issue from being addressed. The paper concludes by suggesting that policies which are ostensibly intended to improve housing affordability will continue to founder until the ideational obstacles which are the focus of this paper are recognised, and housing policy is reconceptualised along lines more conducive to the amelioration of the housing affordability problem. The paper seeks to extend the existing literature on housing affordability by explicitly identifying the linkages between neoliberal ideas, commonwealth public policy, and the extant problem of housing affordability in Australia.     

Marketisation policies in different contexts: Consequences for home‐care workers in Germany,Japan and Sweden

Market‐oriented restructurings of long‐term care policies contribute significantly to the aggravation of care workers’ situations. This article focuses on the effects of broader long‐term care policy developments on market‐oriented reforms. Germany, Japan and Sweden are three countries that have introduced market‐oriented reforms into home‐based care provision embedded in distinct long‐term care policy developments. Conceptually, this article draws on comparative research on care to define the institutional dimensions of long‐term care policies. Empirically, the research is based on policy analyses, as well as on national statistics and a comparative research project on home‐care workers in the aforementioned countries. The findings reveal the mediating impact of the extension and decline of long‐term public care support and the corresponding development of the care infrastructure on both the restructuring of care work and the assessments of the care workers themselves.     

老年人日常照料的角色介入模型

本文在总结国内外老年人照料研究的基础上,提出老年人日常照料的角色介入模型,其核心是三个规律：即（1）成本命题：一个角色介入老年人日常照料的成本越大,其介入照料的概率就越低;（2）邻近命题：与被照料者的地理和社会邻近度越高,照料角色介入的可能性就越高;（3）责任命题：对被照料者的责任感越高,照料者介入的可能性就越大。由此三个命题所延伸出的六个假设,通过多元正态概率模型对2000年“中国城乡老年人口状况一次性抽样调查”的原始数据进行分析,结果显示,多数假设得到数据的支持。这一研究结果对厘清老年人照料的社会化和家庭照料之间的关系及其理性的公共政策选择,提供了新的视角和理论依据。     

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.     

A Comparative Case Study of Care Systems for Frail Elderly People: Germany, Spain, France, Italy, United Kingdom and Sweden

Comparative studies of European social policies towards frail elderly people typically focus on the systems and their implementation. The study presented in this article, conducted in 2001 in six European countries (Germany, Spain, Italy, France, the United Kingdom and Sweden) aims at comparing the rights of the individuals within the different care systems. The methodology used is a case study approach, which draws on a series of situations of dependent elderly people. Therefore, the analysis focuses on the public authorities’ responses – the care packages, which determine the type of care required and the financial contribution of the user – in each of the six countries, in relation to the concrete situations of frail elderly people. As local variations are important, in all the countries studied, local authorities have been chosen in each of the countries. This approach gives us interesting concrete elements on the services and financial help which can be given to frail elderly people, but it also enables us to understand precisely the national care systems organized in the different countries and the main difficulties encountered by public authorities in facing this problem of frail elderly people.     

A policy perspective on elder justice through APS and law enforcement collaboration

The policy issues involved in the social problem of elder victimization could fill volumes. Even the policy issues involved in the new concept of elder justice are multi-faceted. Through the lens of a policy analysis perspective, the history, ideologies, politics, social movements, and economics of policies that promote the collaboration between adult protective services and law enforcement are examined. The analysis of state and local policies as well as a promising federal legislative initiative will, hopefully, help policy advocates understand from where the movement toward collaboration between adult protective services and law enforcement has come as well as where it may be headed.     

Devolution and Patient Choice: Policy Rhetoric versus Experience in Practice

Background: market reforms in England have been identified as making a clear distinction between English health policy and health policy in the devolved systems in Northern Ireland, Scotland and Wales. Patient choice is a high profile policy in the English National Health Service that constitutes significant changes to the demand side of health care. It is not clear what national differences this has led to regarding implementation of policy. This article presents the findings from a large UK‐wide study on the development and implementation of policies related to patient choice of provider. The findings reported here relate specifically to the policy development and organizational implementation of choice in order to examine the impact of devolution on health care policy. Aim: this study examines patient choice of provider across all four countries of the UK to understand the effect of differences in national policies on the organization and service how choice of provider presented to patients. Methods: at the macro‐level, we interviewed policymakers and examined policy and guidance documents to analyze the provenance and determinants of national policy in each UK nation. At the Primary Care Trust or Health Board level, we interviewed a range of public and private health service providers to identify the range of referral pathways and where and when choices might be made. Finally, we interviewed ear, nose and throat, and orthopaedics patients to understand how such choices were experienced. Findings: while we found that distinct rhetorical differences were identifiable at a national policy level, these were less visible at the level of service organization and the way choices were provided to patients. Conclusion: historical similarities in both the structure and operation of health care, coupled with common operational objectives around efficient resource use and waiting times, mediate how strategic policy is implemented and experienced in the devolved nations of the UK.     

Return of the Nanny: Public Policy towards In‐home Childcare in the UK,Canada and Australia

Research on early childhood education and care (ECEC) policy focuses overwhelmingly on formal, centre‐based provision and, to a lesser extent, on family day care (or childminding) provided in the homes of registered carers. Comparatively little research addresses the policy treatment of care provided in the child's home by nannies and au pairs. This article examines the position of in‐home childcare in Australia, the UK and Canada, and the varied nature and extent of public funding and regulation. Introducing a new dimension into comparative studies of ECEC, it also explores how shifts in migration policy in each country have intersected with ECEC funding and regulation to reshape the recruitment and employment of in‐home child carers. Australia, the UK and Canada are all liberal, market‐oriented countries, but there is considerable diversity in the way governments support and regulate in‐home childcare, their rationales for so doing, and in the connections between childcare and migration. We argue that connecting the analysis of in‐home childcare to migration policies raises new questions about the classification and comparison of ECEC policies.     

Reorganizing Social Policies through Social Partnerships: Greece in European Perspective

In postwar Western Europe social policies in the wider sense relied in many countries on neo‐corporatist policies of implementation. Since the 1980s such policies have ceased to be as dominant as they used to be, being associated with what has been called “policy communities” and “policy networks”. As far as the reforms pursued by many countries in order to readjust their economies and labour markets are concerned, significant shifts of such a kind were observed. Illustrations of these trends are presented in a comparative section. We attempt to demonstrate the dual structures of social policy formation and implementation, i.e. neo‐corporatist and network/policy community policies, and to discuss the “how” of such policies, i.e. their “raison d’être” and their “real world” enforcement. Against a background of various semi‐corporatisms and adversarial trade union politics, Greece is trying at the moment to adopt this pattern in several social policy areas, though this is not yet quite visible. Neo‐corporatism is also enhanced. We attempt to show where neo‐corporatism is tried (e.g. certain “social dialogue” structures) and where policy communities are encouraged (e.g. public health, local social policies, etc.). Sometimes the boundaries between the two systems are blurred, with some social dialogue committees appearing as quasi‐policy communities. Finally we endeavour to examine the outcomes of such policies and to see their inner logic against the theoretical background. The concept of multilevel governance as a wider policy instrument which incorporates both the above systems is of special interest here.     

From Subsidiarity to 'Free Choice': Child- and Elder-care Policy Reforms in France, Belgium, Germany and the Netherlands

This article analyses the patterns of reform in care policies in Bismarckian welfare systems since the early 1980s. Based on a comparison of France, Germany, Belgium and the Netherlands, the article shows that these reforms share similar logics and trajectories, which can be explained by the shared conservative and corporatist traits of Bismarckian labour markets and welfare state institutions and their impact on labour market adjustment possibilities and preferences. Indeed, we argue that care policy reforms have been very closely linked to specific employment strategies, and the politics of welfare without work and subsequent attempts to shift away from such a labour-shedding strategy go a long way in explaining both the nature and the timing of child- and elder-care policy reforms in Bismarckian welfare systems. The article also shows how a focus on promoting ‘free choice’ in all four countries has justified the introduction of measures that have simultaneously reinforced social stratification in terms of access to the labour market – meaning that some women have much more ‘free choice’ than others – and weakened certain labour market rigidities. To conclude, we argue that care policy reforms have provided a backdoor for the introduction of labour-cheapening measures and for increasing employment flexibility in otherwise very rigid labour markets.     

Breaking down ideas and institutions: the politics of tax policy in the USA and the UK

As the existing comparative policy literature suggests, both ideational and institutional analyses have clear analytical value in their own terms but, under many circumstances, it is the combination of the two perspectives that allows for a full understanding of policy trajectories. In this article we suggest that, to improve our understanding of how ideas and institutions interact to produce change, it is important to break down these two overly broad concepts. This is because beyond general arguments about how ‘ideas’ and ‘institutions’ interact, students of public policy should itemize ‘ideas’ and ‘institutions’ into more focused, and empirically traceable, subcategories while recognizing the changing and contingent nature of their interaction, over time. To illustrate this, we turn to the politics of tax policy in the United States of America and the United Kingdom, tracking developments from the rise of the New Right and an aggressive income tax cutting agenda, personified by President Reagan and Prime Minister Thatcher, through to the revived debate about the legitimacy of increasing taxes on those earning the highest incomes that emerged in the era of austerity that followed the Great Recession of 2008.     

Analysis and Advocacy in Home- and Community-Based Care: An Approach in Three Parts

A new chapter in health policy presents both challenges and opportunities for aging policy analysts and advocates concerned with long-term care. Millions of long-term care recipients and providers live today in a pubic policy netherworld, one principally associated with Medicaid. I suggest here that moving policy forward will entail three key steps: (a) to overcome structural lag in key home and community-based care (HCBC) policy arenas; (b) to reverse a contemporary pattern of risk-shifting from institutions to individuals; and (c) to inform and empower caregivers to have their own pressing needs recognized. Recent developments in Washington provide new optimism on these fronts. Voluntary long-term care and community-based care (LTC/HCBC) proposals are on the table within the broad context of health care reform. Whether they remain will be, in large, part a function of how far we have moved along the fronts described: modernizing policies, recognizing risks, and activating neglected policy constituencies.     

Caregiving in Transition in Southern Europe: Neither Complete Altruists nor Free-riders

In the framework of the SOCCARE Project, focusing on families dealing with a double front of care for children and frail elderly people, similarities can be found in Italy, France and Portugal beyond their different welfare regimes. The comparison of family histories and caregiving strategies, by the methodology of case‐matching, gives an interesting overview of the relationship between the debate on social care and that on the intergenerational contract. The paper aims to understand which are the available combinations of family, informal and institutional resources making a heavy burden of care “acceptable and still normal”: this focuses both typical situations of each country and common features through the countries. The results show how changes in the representations of obligation and duty in the intergenerational pact produce different outcomes and demands in welfare systems. The analysis of shifting boundaries between the public and private spheres in care provides useful policy recommendations, aimed at improving choices and “sustainable” responsibilities of individuals, families and social networks. Sustainable policies seem to be more dependent on family and structural types and resources of networks than on different welfare and services support.     

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.     

The “ugly” face of social investment? The politics of childcare in Central and Eastern Europe

In this article, we aim to understand the development dynamics of a specific area of social investment (SI), that is, childcare policies, in the context of postcommunist politics and the recent right-wing turn that took place in the Czech Republic, Hungary, and Poland. This article identifies varieties of channels for promoting SI. First, in taking the perspective of the “mixed economy of welfare,” we argue that attempts made to introduce elements of SI to the childcare policies involved various leading roles available for either the private sector or state/public domain. Second, it is important to distinguish between implicit/unintended and explicit/intended projects both in relation to cases in which SI strategy is applied via marketization/privatization and when it involves a government-led project. Third, we take into account the politics of SI implementation that might involve applying certain principles central to policy concepts (such as “investment”) in justifying policy instruments incompatible with original ideas. Although arguments about SI have been extensively used by Eastern European leaders, their goal has been to justify welfare reforms that were implicitly or explicitly directed towards the middle class while excluding the “nondeserving” often based on ethnic identity. We characterize Poland as a case of “implicit marketization,” the Czech Republic as a case of “explicit privatization,” and the Hungarian version of SI as a case of “explicit public dualization.” In this, we show that in some cases, the implementation of SI approaches by right-wing populist parties might rear its “ugly” head.     

Big Business in a Thin Market: Understanding the Privatization of Residential Care for Children and Youth in Sweden

This article analyzes the transformation of Swedish residential care for children from a regionally coordinated, public social service system into a thin, but highly profitable, national spot market in which large corporations have a growing presence. Marketization and privatization are theorized as complex processes, through which the institutional structure and logics of this small, but significant, social policy field changed profoundly. Using official documents, register data, media reports and existing research, three consecutive phases in the development of the children's home market are identified since the early 1980s. Change was driven on one hand by policies inspired by New Public Management, which shifted public authority horizontally to the private sector, and vertically to local authorities (funding) and to the state (regulation). On the other hand were the responses of local authorities and private actors to the changing incentives that policy shifts entailed. During the first two phases, both the proportion and size of for‐profit providers increased, and the model of family‐like care was replaced by a professional model. Cutting across the trend of privatization in the third phase was establishment of a parallel system of homes for unaccompanied refugee children – mostly in public ownership. Similarities with privatization in the English system of children's care homes are noted. By showing how the Swedish market for residential care has been created by policy and by actors’ responses to those reforms, the article provides a foundation for thinking through how the predictable, significant and well‐documented problems of such care markets might be addressed.     

A Comparative Discussion of the Gendered Implications of Cash-for-Care Schemes: Markets, Independence and Social Citizenship in Crisis?

There are moves across many countries away from state-led provision of services for disabled people towards cash-based systems, which have been welcomed by disabled people as increasing choice and control over services and support, and increasing independence and social participation. However, feminist scholars have long warned about the implications of commodifying care for women, and the possible consequences of substituting cash for services for social citizenship have remained underexplored, for both disabled people generally, disabled women and mothers more particularly, and for personal assistants/care workers. This article will attempt to address that gap by carrying out a comparative literature review and policy analysis of the role of policy development and outcomes in cash-for-care schemes, looking comparatively across policy developments in several countries, as well as developed welfare states beyond Europe to examine: (a) the impact of the tensions between various governance levels, particularly local and national government; (b) the gendered impact of such policies on (for example) gendered divisions of paid and unpaid work, citizenship and social participation; (c) the impact such policies have, or are likely to have, on different groups of men and women across the life course and across different social and economic groups; and (d) how such policies can contribute to the well-being and/or detriment of different groups of women (and men) within different social, political, economic and historical contexts.     

European Health Care Costs

The rising cost of health care in Western European countries is now seen by many governments as a problem, and attempts are being made to find a solution by introducing cost-containment policies.
The author begins by reviewing trends in health care expenditures, and examines some of the underlying reasons for the upward trend.
He then considers some of the more important differences in the organization and financing of Western European health care systems, before surveying the different kinds of cost-containment policies which are being, and could be, pursued.
The conclusion is that present cost-containment policies do not take sufficiently into account the underlying reasons for rising costs, and that the criteria for evaluating the success of these policies are inadequate. To be successful, the policies will have to be altered, and the objectives and means of evaluation reconsidered.