1. Welfare states and health care systems Lecture 2
Ana Rico

2. STEPS IN INDUCTIVE POLICY RESEARCH
DESCRIPTION
Definition of the WS
Types of welfare states and health care systems
- Which are the relevant policy instruments in each sector?
Evolution trends
- Do different types evolve differently (diverge) or similarly (converge)?
ANALYSIS
Causes = determinants
- Economic (e.g. industrialization, GDP growth), social (e.g. Illness, poverty, social structure), and political (e.g. voting, government coalitions)
Consequences = social, economic and political impact
- Which impact upon poverty, health, unemployment? National/by social group
Policy implications
- Which policy instruments should be selected in each country and sector, given the national configuration of causes, and the evidence on their consequences?

3. THE WELFARE STATE (Esping-Andersen, 2000 & 2003)
OUTLINE OF THE SESSION
INTRODUCTION
THE WELFARE STATE (Esping-Andersen, 2000 & 2003)
1. Definition and measurement
2. Types of WS in Europe: Policy instruments
3. Consequences/outcomes
4. Causes of the welfare state: origin and evolution
NATIONAL HEALTH CARE SYSTEMS (Blake & Adolino, 2001)
Types: Beveridge, Bismark, (Shemashsko), Residual/market-based
5. Evolution and policy instruments
6. Determinants
7. Policy implications

4. 1. THE WS: Definition and measurement
Role of the state in the protection against life risks: A big public insurance company (Social Security), which also owns, or contracts with, a service provision company/ies (eg the British NHS)
It usually includes:
- Cash benefits: old age, unemploym., sick leave, maternity pensions
In-kind benefits or welfare services: HC, social care, education
But when is protection against risks extensive enough for an state to be called welfare state?:
Initially: only states with universal, free programmes (Briggs 1969)
Later: most civil servants work in welfare (Therborn 1983, quoted by Esping-Andersen 2000)
Nowadays: At least 3 nearly universal programmes Mahoney (2004)
WS regimes: role of state/market/family in protection from risks

5. 1. THE WS, POLITICS & MARKETS: Definition
GOVERNANCE & POLITICS
DEMOCRATIC GOVERNMENT & INSTITUTIONS
INTEREST GROUPS
THE MARKET
Financial markets
PUBLIC & SOCIAL INSURANCE
THE WS
PRIVATE FINANCERS: Banks, insurers, citizens
Product markets
PUBLIC WELFARE SERVICE PRODUCTION
PRIVATE PROVIDERS: Hospitals, doctors, schools, nursing homes

6. 1. THE WS: Definition and measurement
Quantitative indicators: expenditure (per hab. or GDP), % employment
Qualitative indicators: nature of entitlement (poverty, employment, citizenship), ´decommodification´ (= universal = benefits independent of employment or income), coverage (% population), generosity of benefits, number of programmes covered
Types of WS:
Different types of WS: depending on values/ranking in quantitative and qualitative dimensions
Causes of WS Main theses nowadays:
Different types of WS (HC systems) have different causes
Different WS sectors (eg pensions, HC) can be of different types, and have different causes

7. 1. & 2.: THE WS, Measurement & Types
Conservatism
ITA
AUS
GER
BEL
FRA
FIN
IRE
JAP NZ
NETH
NOR
USA
CAN UK
DNK
SWE
AUZ
SWI
Neo-liberalism
Socialdemocracy
Based on Hicks & Kenworthy 2003

8. 2 & 1. TYPES OF WS: Types and policy instruments
(THREE + 1) WORLDS OF W CAPITALISM? (Esping-Andersen 1999)
PUBLIC EMPLOYMENT AS A OF TOTAL
(% STATE PRODUCTION)
HIGH
LOW
SCANDINAVIA UK
Spain
Italy
SHI COUNTRIES
Austria, Germany
Belgium, Neth., Lux.
Canada
Portugal
Greece
CEE (2)
USA, Australia, New Zealand
Switzerland
CEE (1)
SOUTH-EU (1)
PUBLIC SOCIAL EXPENDITURE AS % OF TOTAL
(% PUBLIC INSURANCE)
SOUTH-EU (2)

9. EGALITARIAN Outcomes REGRESSIVE
2 & 3. TYPES OF WS : Instruments and consequences
UNIVERSAL
Pure (unmixted) Socialdemocratic
Pure Christian Democratic: Employees
EGALITARIAN Outcomes REGRESSIVE
% Covered
Pure liberal: Private insurance for the non-poor
Pure liberal: Public insurance for the poor
Pure ChisDem: Non-employed
Pure CD: Private insurance for employers
RESIDUAL
Based on Esping-Andersen, 1990

10. 2 & 3. TYPES OF WS: Instruments and consequences
I. THE SOCIAL DEMOCRATIC WORLD
1. Policy instruments
Redistributive financing & benefits
Universal access (citizenship)
Public provision of services
Expanded services, active labour mkt & gender-egalitarian policies
2. Policy (outputs &) outcomes
Public expenditure: High (output)
Income:  Poverty & class inequality
Employment:  gender & class inequality
Main beneficiary: poor citizens/residents
working women
II. THE CONSERVATIVE (CHRISTIAN DEMOCRATIC) WORLD
1. Policy instruments
Proportional financing & benefits
Profess. groups (employm.-based)
Private (NFP) provision of services
Cash transfers across life cycle
2. Policy (outputs &) outcomes
Public expenditure: High (output)
Income:  inequality of workers at risk
Employment:  total levels of employment
Main beneficiary: middle-class families
III. THE LIBERAL WORLD
2. Policy (outputs &) outcomes
Public expenditure: Low
Income:  Extreme poverty,  inequality
Employment:  total levels of employment
Main beneficiary: PUB: poor/old citizens
PRIV: the wealthy
1. Policy instruments
Regressive financing & benefits
PUB: Redistr. PRIV: regressive
Means-tested (income)
Private (FP) provision of services

11. THE 3 WORLDS OF WELFARE CAPITALISM = National configurations of:
2. TYPES OF WS
THE 3 WORLDS OF WELFARE CAPITALISM = National configurations of:
* Social structure: Distribution of power, income, rights, status across social groups 
Political ideologies (or subcultures)
* Partisanship (party/ies in government) 
* WS Policy instruments 
* Policy outcomes by social group (distributional consequences)
The liberal world
The conservative world
The social demo-cratic world

12. 4. CAUSES OF THE WS
Initially, Esping-Andersen theory was actor-centred (political parties):
Socialdemocratic parties in government
(Scandinavian) Welfare state
Social structure and national culture
As a reaction to social determinism in early marxist theory:
Social structure
Policy
Political party
In the 2000s, his theory becomes action-centred (and multi-causal):
- what matters is not whether SD present in government, but
- how they played the political game: mobilization in the streets, coalition with ‘middle-class’ parties, success of their prior policies

13. 4. CAUSES OF THE WS: Origin and evolution
Christian & conservative parties, unions & voters
Political competition: * Electoral campaigns * Policy campaigns
Political mobilization
Coalitions
Dominant national subcultures
Socialdemocratic parties, unions & voters
Social structure
Policy change
Liberal parties, progressive (state) elites, social protest
SOCIAL
SOCIOPOL.
POLITICAL
POLICY
Based on Esping-Andersen 2000 & 2003; Jenkings & Brents 1987; Skocpol 1987

14. 4. CAUSES OF THE WS: Origin and evolution
Catholic parties & unions
Christ.democratic parties
Nationalist parties
Anti-democratic parties
CONSERVATIVE
SOCIALDEMOCRATIC
LIBERAL
Individual and collective :
POLITICAL ACTORS
The Church
The Army
Aristocracy
Landowners
Monarchists
Nationalists
Fascists
Small owners
Socialist intellectuals
Socialist party elites
Socialist tradeunionists
Blue-collar industrial workers
Very poor agricultural workers
Middle-class agricultural workers
(White-collar indust. & service workers)
Socialdemocratic parties
Class-based unions
Agrarian/rural parties
(Professional unions)
Liberal elites
Employers
Financers
Exporter landowners
Liberal parties
Bussiness associations
Liberal professions (eg doctors)
Professional associations
Based in Esping-Andersen 1990 & 2003

15. 4. CAUSES OF WS: Origin and evolution
Action-centred arguments
National culture is not given, but rather a consequence of politics
The socialists were a main cause of the WS, even when not present in government (state actor)  still influential as a pressure (sociopolitical) group, via political mobilization
When in government, coalitions with other actors critical to explain success in WS development
CONCLUSIONS: Main theses
National cultures and WSs result from political struggles among ideological subcultures represented by competing coalitions, by which one became predominant over (but didn’t eliminate) the others
In each WS subsector, an specific combination of conservative, liberal and socialdemocratic policy instruments exist, which is the result of the varying success of different competing coalitions.
Based in Esping-Andersen 1990 & 2003

16. 4. CAUSES OF THE WS: Evolution
The increasing interpenetration among the 3 worlds
1. A common conservative historical origin (=Ancient Regime, absolutism)
Characterized by (church) charity for the poor + guild-type mutual funds for the employed + extensive welfare role of family (women)
Which became predominant in countries with weak liberal & socialdemocratic subcultures: the ChrisDem reform path, SHI crowds-out most private market
2. A competing liberal reform path (emerging in , back in s)
Initially oriented to undermine Conservatism: public system substitutes charity; and markets substitute mutual funds
Initially wins the battle in Anglosaxon, then Scandinavian countries
Later oriented to undermine socialism; + slowly penetrating rest of the world
3. A socialdemocratic reform path (emerging in , dominant in )
Which aimed first at removing 1.: Unions (& then the state) take over charity
And then competes with 2.: The state takes over the private market too
Varying penetration across EU: dominant in Nordic, SouthEU, UK NHS, CEE.
Based in Esping-Andersen 2003

17. THE US EXCEPTION
In WS cash transfers, similar to conservative model (if less generous)
In HC, liberal  very limited role of the state (less than 50% of pop.)
1930s: Succesful pro-poor WS (cash transfers) reform BUT failed health care reform  1. Success WS + 2. Failure HC
* Europe: s pro-poor WS + HC
1960s-1970s: Succesful pro-workers pension reform, limited unemployment reform, and very limited (pro-poor & aged) health care reform  1. Partial success WS + 2. Limited success HC
* Europe: s  Universal or pro-workers WS & HC (but Switerland, pro-workers HC in 1999)
1993-4: Failed universal health care reform  Failure HC
* Europe: 1970s-90s  Further expansion of WS:
From pro-workers to universal in CD WS
New programmes (eg social care) in SD WS

18. Source: McKee, 2003

19. 5. NATIONAL HEALTH SYSTEMS: Evolution & instr.
HC POLICIES
Mutual Aid Society Legislation
Social
Health Insurance
National Health System
HC SYSTEMS
NHS
Britain
Sweden
Denmark
Italy
Spain
1793 +, 1850 *
1891 +$, 1910 *$
1892 $ *
$ * #
1859 $ #
1911 %
[1919 %] 1931 % 1946
[1919 %]
[1919 %] 1944 &
1942 % 1967
1946 €H
R 1969 € 1946 && [1948 NHS]
1971 && NHS
1978 € R
1986
SHI
The Netherlands
France
Germany
Belgium
Austria
1852 $ + * 1898 #
1849 $ 1898 *
[1919] $
[1928 %] 1930 % 1945 &
1883 %
1944 &
$ # 1939 * €H
SYMBOLS
[failed reforms]
Regulation of mutual funds
+ Special interest rates
$ Government subsidies
* Regulation of activities
# Political controls
Social Health Insurance
% Compulsory, low-income workers
& Compulsory for all salaried workers
National Health Service
NHS National Health Service
&& Universal
@H Gov. ownership of hospitals
@PC Gov ownership of PC
€ Full-time salaries (Hosp, PC)
R Restrictions on private practice
Based on Immergut E (1991): Medical markets and professional power: The economic and political logic of government health programmes, Working Paper 1991/24, Center for Advanced Studies in the Social Sciences, Juan March Institute, Madrid, Spain.

20. 6. DETERMINANTS OF NHI REFORM
Cultural explanations
National culture (stable): Liberalism/individualism in Anglosaxon countries = “a distrust of government solutions to societal problems”
Economic explanations (Convergence th): omitted, controlled by design: Does not explain differences among developed countries + US exception
Institutional explanations
A. Executive dominance: “Parliamentary systems feature stronger party discipline..., and greater centralization of legislative authority in the cabinet”
B. Federalism
C. Corporatism (as an indicator of interest groups’ formal political power)
Political explanations (political actors and political action)
Strong left political parties in government
Public opinion: omitted from the analysis (see pp )
Interest groups: omitted, “the uneven success of IGs in blocking NHI points to the need to model the nature of IGs group politics”
Political leadership, strategy, policy model: ommitted (see pp.702-3)
From here on: Based on Blake & Adolino 2001

21. 6. DETERMINANTS OF NHI REFORM: QCA measurement
CONFIGURATIONS
COUNTRIES
Success NHI
Failure NHS
5 factors +: SUELC
4 factors +: SuELC
SUeLC
SUElC
Sweden, Norway
Austria
Denmark, Finland
Luxemburg 2 1
3 factors +: sUELc
SUeLc
SUElc
SUelC
SueLC
United Kingdom, New Zealand
Iceland
France
Japan
Belgium, Germany, Netherlands 3
2 factors +: SUelc
sUElc
SuELc
sueLC
Italy
Ireland
Australia, Canada
Switzerland?
1-0 factors +: suelC
suelc
USA
Supportive culture Unitary Executive dominance Left rule Corporatism

22. 6. DETERMINANTS OF NHI REFORM: Analysis
In the most generous WS, all 5 causes present: NOR, SWE
Given a supportive culture, a left party, and a corporatist pattern of IGs intermediation, NHI enacted even if unfavourable political institutions
AUS, DEN, FIN, BEL, GER, NETH
3. Unitary states with supportive cultures, enacted NHI even if rest of conditions unfavourable
ICE, FRA, ITA, JAP
4. Anglosaxon countries with a dominant executive and left parties enacted NHI in spite of rest of factors unfavourable
UK, IRE, CAN, AUSL, NZ
5. Causes of American excepcionalism: “The USA [is] the only country with unfavourable conditions in all 5 vars.”
MAIN CONCLUSION: “To date, the absence of favourable [(political) institutions] has only been overcome by the simoultaneous presence of all three other supportive factors (culture, labour party, corporatism)”

23. 7. POLICY IMPLICATIONS FOR THE USA (pp. 702-3)
A. Reform political institutions (institutionalists)
Unlikely, rules of constitutional revision very tough
 OK for Executive dominance and Fedralism, but what about party discipline (part of E) or corporatism (C)?? NOTE: C defined as an institution, but in the discussion treated as a sociopolitical actor (Unions)
B. Mobilize political support (action-centred)
Need for the (1) Democratic party to overcome internal divides: progressive statists (similar to SD) mixed with liberals/conservatives
 NOTE Amenta (2004) on North/South divisions within D party
Need to develop strategies for (2) influencing public opinion, so that a supportive culture can develop; (3) mobilizing sociopolitical actors (e.g. citizen associations, social movements) which could play the role of unions
 NOTE Briggs (1961) on USA 1935 SS Act and UK 1945 NHS