Lecture 7 Health Politics Ana Rico ana rico medisin

Lecture 7 Health Politics Ana Rico ana. rico@medisin. uio. no 2005 Institutional theories. The role of political institutions

The old institutionalism I. Research question § Which is the impact of political institutions and the social structure on democratic politics and policy change? § Majority and consensus democracies, plurality and proportional electoral systems, presidentialism, parliamentarism, federalism III. Thesis and arguments § Institutions which disperse power across political and sociopol. actors are more democratic (responsive) & equally effective III. Anti-thesis: the new institutionalism § Concentrated state power needed for effective policy change IV. Aplications – evidence § Political institutions in Western Europe (Liphart, 1984; 1999) VI. Policy implications Power concentration is good for passing controversial policy, but can have high political and implementation costs 2005 II. Main concepts - definitions

SOCIAL & POLITICAL THEORIES 1950 s/60 s: SOCIAL CONTEXT L 3 SOCIAL PRESSURES OLD INSTITUTIONALISM Formal political institutions L 2, L 4 L 5 POLITICAL ACTORS (STATE: independent of social pressures) L 6 1990 s: INSTITUT -IONALISM (+state-society) SOCIOP. ACTORS (STATE-SOCIETY: interdependent) L 9 POWER-CENTRED THEORIES (interactions among collective actors & social structure) L 7 NEW INSTITUTIONALISM (state institutions & state/PPs/IGs’ organization) L 4, L 9 RATIONAL CHOICE (interactions among individuals L 7, L 9 ACTOR-CENTERED INSTITUTIONALISM (interactions among institutions & elites) 2005 SOCIAL ACTORS (IGs: dependent on social pressures) 1970 s/1980 s: ACTORCENTRED 2000 s: ACTION THEORIES L 7

CONCEPTS (4): The state § SOCIAL CONTEXT: The state as a ‘transmission belt’ of social pressures § STATE-SOCIETY: The state as a set of political representatives and policy experts with preferences and action partly independent, and partly determined by a wide range of social actors’ pressures § INSTITUTIONALIST: The state as a set of political institutions; or as a set of elites with preferences and actions mainly determined by institutions § ACTION: As a set of political organizations which respond to context, sociopolitical actors and institutions; and which compete and cooperate (=interact) to make policy § 2005 § STATE-CENTRIC: The state as a unitary, independent actor with formal monopoly of (residual) power over policy-making

ANTECEDENTS (3) Old political institutionalism (Lijphart) • Formal centralization of decision-making power makes political • State powers are more centralized when: Democratic Institutions: Majoritarian (vs proportional) electoral systems; Unitary (vs federal) states; Executive dominance (+/- = parliamentarism vs. presidentialism); Sociopolitical organizations: Biparty/multiparty systems, majority vs. coalition) government; Corporatism (vs pluralism); Party discipline and centralized organization Social groups: Single (=class) vs multiple cleavages in the soc. struct. seen as causes of institutions Single/multiple cleavages biparty/multiparty system single party/coalition gov. centralized democratic institutions 2005 regimes, states and organizations more capable & more efficient

The old institutionalism Types of democratic institutions in the EU CONSENSUS Unidimensional party systems Multidimensional party systems Two party systems Multiparty systems Majority(/plurality) elections Proportional elections Concentration of executive power: majority government Executive power-sharing: coalition governements, corporatism Executive dominance over parliament (Presidentialism) Division of powers (Parliamentarism) Unicameralism or asymm. bicameralism Balanced bicameralism Unitary and centralized Federal and devolved Unwritten constitution Written constitution and protection of minorities Representative democracy, pluralism Forms of direct (corporatist) democracy Lijphart, 1984 Later US research shows that Presidentialisms disperses power more 2005 MAJORITARIAN

The old institutionalism Other arguments and counterarguments (1) LIJPHART’S THESIS • The interplay between social structure, political institutions and sociopolitical groups determines policy • Institutions which concentrate power can be more effective, but are less democratic costs in terms of political support & implementation gaps • Institutions which disperse power across actors are more democratic (minorities´representation, direct political participation), and, under some conditions (cooperation, consensus building), can be equally effective (minorities’ protection, economic growth, income inequality) 2. CRITICISMS (anti-thesis) New institutionalism • Institutions which concentrate state and socio. P power are needed for state capacity/autonomy + effective policy change Actor-centred institutionalism • Institutions which disperse state power allow more points of acess (veto points) for IGs to block policy 2005 1.

The old institutionalism Arguments and counterarguments (2) § Types of political institutions and degree of concentration of power § Majoritarian vs. consensus institutions: Functional division of power –Do. P- among state organizations and political parties § Unitary vs. federal institutions Territorial Do. P – between federal/central and state/local governments) § [Corporatist vs. Pluralist: Do. P between state and social groups)] 2. CRITICISMS NOTE: Later institutionalists socio. P institutions such as party discipline, or minor constitutional reforms in EU 1950 s allowing the Executive to pass legislation by decree, are critical too to promote power concentration 2005 1. LIJPHART’S THESIS (2)

The old institutionalism The electoral system (translates social support/votes into % of state power) A. Proportionality = votes/parliam. seats ( access to govern. & parliament) Main dimensions Maj Prop < % Prop > Electoral thresholds > District magnitude Small Ballot structure 1/2 rounds Supplementary seats No Big Yes C. The social and socio. P power structure: Cleavages & pol. parties NON-PLURAL (2 -3 SEMI-PLURAL (3 -5 parties, 1 cleavage) parties, 1 -2 cleav. PLURAL (> 5 parties, 2 -3 cleav. ) Relig. /linguistic homogeinity UK, Ireland Finland Austria New Zealand France Israel HIGH Scandinavian Italy Luxemburg Religious/ling. heterogeinity Australia Germany Belgium Canada Netherland United States Switzerland LOW Lijphart, 1984 < 2005 Electoral formula

The Do. P between Executive & Parliament The electoral system United States United Kingdom Philippines Canada Puerto Rico Australia Ex-Soviet MAJORITARIAN (plurality) PARLIAMENTARISM Prime Minister strong, elected by Parliament New Zealand Asia Africa PROPORTIONAL France Switzerland South America Lijphart, 1994 Most Western Europe 2005 PRESIDENTIALISM: President elected by citizens, strong Parliament

Modern institutionalist theory I. Research questions § Are institutions the main cause of policy? Do they determine actors’ behaviour? II. Main concepts - definitions Types of political institutions; path dependence and institutional inertia. III. Thesis and arguments § New institutionalism: (1) Institutions determine actors’ preferences, resources and strategies, and therefore reinforce and reproduce the status quo § Actor-centred institutionalism (infl. by ECO): (2) Formal political institutions modify (weaken or strengthen) the degree of autonomy of state actors from IGs IV. Aplications – evidence § Explaining the emergence of different health care systems V. Policy implications § (1) Institutions do not change, hence big policy turns are unlikely; (2) Changing formal constitutional rules increases the likelihood of state-led policy change, VI. Criticisms § Institutions can be changed through political action and policy reform; lack of change is due to entrenched interest groups and/or reluctant citizens 2005 §

Formal & informal institutions SOCIAL CONTEXT CULTURE POLICY (SUB-) SYSTEM Social organiz. Sociopol. actors: * Ideologies * Ideas • IGs, Prof Ass. , Unions • Citizens, Mass media • Political parties * Org. Struct. * Subcultures /pol. identities Social groups - Communities - Ethnia, gender - Social classes b THE POLITICAL SYSTEM a a. b. c. Policy change • STATE-, POL. PARTs (IGs) * Policy paradigms/ legacies CONSTITUTION Interactions: • Coalitions/competit. Institutions: • Const. (interorg. ) • Organiz. Struct. • Leadership/strategy HC SYSTEM Outputs e d f INPUTS c State actors: Outcomes POLITY Demands and supports Access to the political system Decision-making POLITICS POLICY d. Institutional change e. Impact of policy f. Distribution of costs and benefits OUTPUTS 2005 Associations • Churches • Firms •

The new institutionalism Institutions (including public policies, organizations) block new policy because of their strong resistance to change (inertia) once settled (path dependence) § Institutional inertia/path dependence is in turn due to: § A. Technical/cognitive causes (decreasing returns = economies of scale/scope, learning costs) ECO + some POL. Sci. (eg Pierson 1998, Wilsford, 1995) § B. Normative causes (cognitive rules are given normative meaning through the processes of socialization carried out to guarantee the compliance of individuals to rules; once linked to values, rules become difficult to change) Anthropology, Sociology, ORG THEORY, Policy Anallisys Social embebbedness (Evans) § Policy change happens only as a result of an external shock which opens a policy window for reform 2005 §

Immergut, 1992 2005

Actor-centred institutionalism Determinants of National Health Insurance systems DETERMINANTS FRANCE + + + Interest groups - - - Left vote & unions + - - Unit. Dev. (-) Unit. Centr. (+) Federal (--) Few (+) * 1 st : Multiple (-) Multiple (--) Policy idea SWITZERLAND Government’s support Territ. Do. P (‘state capacity’) Veto points/(Do. P E/P/C) * 2 nd : Few (+) Party system (& discipline) Concentr (+) Dispersed (-) NHS (++) SHI (+) Highly disp. (--) * Influenced by electoral system POLICY CHANGE * 1 st : Immergut, 1992 * 2 nd : + PI (-) 2005 SWEDEN

Veto points SOCIAL CONTEXT POLICY CONTEXT Social organiz. THE POLITICAL SYSTEM Sociopol. actors: • NEW SOCIAL MOV. • MASS MEDIA • IG & PROF ASS • POLITCAL PARTIES Social groups • COMMUNITIES • ETHNIA, GENDER • SOCIAL CLASSES b a Institutional framework 2005 • ASSOCIATIONS • CHURCHES • FIRMS Policy actors: • STATE ACTORS • IG & PROF ASS • POLITCAL PARTIES c Policy change HC services Interactions Outputs d e f INPUTS a. b. c. Implementation Outcomes POLITY Demands and supports Access to the political system Decision-making POLITICS POLICY OUTPUTS d. Institutional change e. Impact of policy f. Distribution of costs and benefits

Actor-centred institutionalism § (State) actors and political parties are the main determinant of policy § Institutions increase or decrease their opportunities to influence policy § In the US as in Canada, the main advocate of NHI were small socialdemocratic parties territorially concentrated § In the US as in Canada, the majority of citizens strongly supported NHI in these states/provinces § In Canada, due to open political acess & strong federalism in HC, a tiny socialdemocratic party ruling in one province introduces NHI, demonstrating that can work with good effects outside Europe this helps them convince the reluctant democratic party & public opinion to support it at national level § In the US, weak federalism impedes pro-WS minority parties to govern no demonstration effects possible Maioni, 1997 2005 EVIDENCE: Canada (NHI) vs the US (no NHI) in the 1960 s

CAUSES OF NHI: CANADA vs USA VARIABLES CANADA 1960 S: NHI USA 1960 s: NO NHI Individualism Medium/weak Weak Strong Weak Yes No Weak Access to governm. No access Underdeveloped CONTEXT. INSTITUTIONS (RULES) 1. Executive dominance 2. Federalism 3. Party discipline ACTORS (PLAYERS) 1. State authorities 2. Pro-WS Pol. Parties + IGs PAST POLICY 1. Past WS policies in HC (a cause of state auton. & capacity) Maioni, 1997 2005 Social values, culture

FEDERALISM IN EU HC NORDIC COUNTRIES POLITICAL DEVOLUTION FISCAL FED. CENTRAL COORD. 2005 ITALY /SPAIN POL. DEVOLUTION FISCAL FED. CENTR? ? UK / GREECE / (PORTUGAL) 60 s 70 s 80 s POL. DEV. ? 90 s 00 s

FEDERALISM & impact of Do. Power 2005 Political OUTCOMES (for democratic representation)

POLICY IMPLICATIONS New institutionalism, path sependence: q Historical determinism: countries are prisioners of history (and individuals of their early socialization experiences/the prevailing social norms) Actor-centred institutionalism (old-institutionalism): debate on q Immergut: Changing formal political institutions towards further concentration of power increases the likelihood of policy change, even if powerful opposed interests q Maioni (with Lijphart): Institutions which disperse power increase access of minority political parties in government and hence the likelihood of policy change 2005 q Institutions do not change, hence once they are established big policy turns are unlikely

CRITICISMS Old-institutionalism § New institutionalism, path dependence: § Political actors can modify some of the rules of the game or ignore them § Part of the causes included under ´institutions´ are rather culture, actors or past policy + state performance § Low explanatory power: it only explains policy inmobility or small changes in policy instrument, but not big policy reforms or instances of path reversal Actor-centred institutionalism, : § Veto points do not only allow private IGs (anti-WS, capture) to block policy, but also public (eg citizens’) IGs to support government policies (pro-WS, democratic participation). § The degree of concentration of political power not only depends on formal institutions, but also on the social structure (eg active cleavages) and actors’ strategies (coalitions, internal cohesion collective action socio. P power resources) 2005 Presidentialism implies dispersion of power across state organizations (President and Parliament), while Parliamentarism implies dispersion of power across political parties and Igs