1. Health care policy POLI 352A

4. Does your health system need reform? Fundamental reform? Completely rebuild system? Canada59%18% United States51%28% United Kingdom60%18% Germany 66%

5. OK, but what’s the problem? High cost / inadequate coverage? Shortage of supply / Waiting times Canada 13% 8% 54% 27% United States 48% 25% 5% 3% United Kingdom 6% 8% 33% 39%

6. How responsive is the system? Ranking United States1 Germany5 Canada7 United Kingdom26

8. How fairly are costs distributed? Ranking Germany6 United Kingdom8 Canada17 United States54

9. Out-of-pocket costs Amount / person / year (US$) Share of health spending United Kingdom$403.1% Canada$30417% Germany$30611% United States$69616%

18. Overall performance ResponsivenessFairnessCost-control United StatesHighLow United KingdomLowHigh CanadaMedium GermanyHigh Medium-low

19. Financing health care Unified financing: taxation –Cost distributed fairly –Easy to cap spending VS. Fragmented financing: Insurers –Hard to cap spending –Unfair distribution if unregulated

20. Delivering health care Public delivery Private delivery (non- or for-profit) –May be more responsive –But cost-control may be harder depending on Payment method – this is crucial –Fee-for-service  more care, higher costs More common with private delivery –Salary / capitation

21. Financing and delivering care Unified (Tax-financing) Fragmented (Insurers) Public United Kingdom France (hospitals) Private (for- or non- profit) Canada Germany (social) United States (private) Financing Delivery

22. Financing and delivering care Unified (Tax-financing) Fragmented (Insurers) Public National health service ? Private (for- or non- profit) National health insurance Social or private insurance Financing Delivery

23. Why policy differences?: Public opinion? Do voters get the health care system they want? Comparison –U.K., Canada, U.S. all individualist cultures Processes –Elite action in UK and Canada precedes public clamour –Much NHI support in U.S.

24. Why policy differences?: Interests? Could outcome reflect the power of interests for and against? Doctors –Oppose state dominance –But to varying degrees, shaped by past policy Labor –Similar strength in Canada/US till 1960s –Labor unrest in US in 1930s –NHI not always creature of the Left

25. Explanation: Hacker on policy feedback Three policy choices have big feedback effects: 1. Policies that encourage private insurance 2.Policies that target vulnerable groups first 3.Policies that promote medical technology Sequence matters.

26. Explanation: Hacker on institutions Institutions determine when moves are made and which policies come first. Shape opportunities of organized opponents (veto points) Shape paths to influence of small, insurgent parties

27. Policy feedback in health care Group interests Costs of NHI Objective policy problems Public opinion Difficulty of moving to NHI later Early health policy choice New politics

28. Policy feedback in Britain Social learning about 1911 failures Vested interests in status quo (inhibits reform) Shapes doctors’ interests Shapes public expectations Early adoption of NHI (1911) New politics

29. Britain: 1911 Institutions allow early adoption of NHI (1911) –Single-party government –Party discipline But early policy matters –Has to accommodate existing insurers –Doctors’ interests shaped by poor prior conditions

30. Policy feedback in Britain New ideas Still-broken system Doctors’ weakened opposition Public support Policy choice (1946): Socialized finance and delivery New politics + Institutions

31. Canada: 1945 Popular support Federal government support Little MD-friendly private insurance BUT Federalism as constraint  No reform

32. Policy feedback in Canada Spread of fee-for-service private insurance Non- adoption of public insurance (1945) New politics

33. Canada: 1950s - 1960s NOW: Federalism as opportunity 1.Regionalism aids socialist insurgent party –CCF wins provincial office –Launching pad for federal NDP 2. Fiscal equalization encourages innovation  Hospital insurance in SK  Imitation by BC, AB, ON

34. Policy feedback in Canada Widespread private insurance + federalism Public fee- for-service insurance (1966) New politics

35. United States 1910s: Support for socialist and third parties –But electoral institutions  no federal seats Weak national party competition, Republican nat’l dominance  Reformers had to fight in states –Inhospitable institutional terrain Large number of units Fear of business exit because of lack of fiscal equalization Strong, business-friendly state courts

36. United States New Deal – huge potential opening but: –Veto points –Lack of party discipline  No reform Repeated under Truman+

37. Policy feedback in U.S. Spread of employer- provided insurance –Satisfies doctors –Satisfies unions –Excludes old and poor Non- adoption of public insurance (‘30s & ‘40s) New politics Public fee- for-service insurance for elderly and poor only

38. Policy feedback in U.S. Exploding public costs Best-organized groups satisfied Vested interests in current arrangements New politics Failure of Clinton plan (1994)

39. Health policy and feedback Current health policies NOT a direct reflection of nat’l values or public preferences –Narrow, well-organized interests matter –Current policy choices constrained by past choices Current organization of interests and public preferences shaped by past policy choices Sometimes policy is not chosen –Emerges through political interactions over time Especially strongly shaped by past policy choices, sequence –Large role for investment –Well-organized vested interests