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The health domain has served as a focal point for investigating the emergence and extension of state capacities for social governance in Western Europe. Such studies have considered, on the one hand, the desire and ability of nation–states to govern the health sector, and, on the other, the amenability of the health sector to governance. Governance, in this case, refers to eﬀorts by governments to intervene in the private provision of medical services. Not only have governments throughout Western Europe underwritten the costs of medical care, they have introduced standards and mechanisms for the control of the quality, availability, and cost of medical services. Consequently, governance of the health sector has entailed government regulation of medical practitioners, and hence, political conﬂict between doctors and the state.
1. Health Politics
1.1 Interest-Group Politics
Political scientists have regarded the health area as a test case for the theory of political pluralism. Pluralist theory focuses on interest groups as the key actors in the political process. Citizens, the theory assumes, form interest-groups when confronted with problems, and use these groups to lobby for the resolution of these problems. As a result, both the array of organized groups and the pattern of governmental activity should, in theory, reﬂect these popular demands. Studies of the role of medical associations in health politics have called this model into question, however. Medical associations appear to have had a strong inﬂuence on health policy decisions. To the extent that medical associations are able to veto any proposal to which they are opposed—by threatening to go on strike or by questioning the medical soundness of government programs—one can speak of ‘undue’ or excessive political inﬂuence, or even of professional dominance. Although successful interestgroup inﬂuence is part and parcel of the pluralist paradigm, such one-sided inﬂuence would constitute a fundamental challenge to the pluralist ideal of politics as a compromise amongst competing interests.
1.2 History Of Health Insurance: The Nineteenth Century
Research on Western European health politics has investigated the conﬂicts surrounding public health insurance programs. Beginning in the late eighteenth and early nineteenth centuries, many European governments introduced laws for registering and subsidizing voluntary mutual aid societies or sickness funds (Friendly Societies, Hilfskassen, Mutuelles, Societa di Mutuo Soccorso), which provided their members with cash beneﬁts and medical treatment. National mutual aid society legislation was enacted in Britain in 1793, Spain in 1839, Belgium in 1849, France in 1834, Italy in 1886, Sweden in 1891, Denmark in 1892, Switzerland in 1911. Early laws—those passed before 1850—were most concerned with monitoring the activities of these popular associations. After 1850, government legislation often included funding for the mutual aid societies. In the late nineteenth and early twentieth centuries, lawmakers made the subsidies conditional on improvements in insurance coverage and medical beneﬁts, requiring, for example, that funds accept all applicants and that they provide access to medical treatment, rather than only the more common cash beneﬁts, which were to cover income-loss during illness.
After Germany introduced compulsory public health insurance (gesetzliche Krankenversicherung) for industrial workers in 1883, many other European nations followed. Austria introduced compulsory health insurance in 1888, Luxembourg in 1901, Norway in 1909, Britain in 1911, the Netherlands in 1913 (for cash beneﬁts only) and in 1943 (for medical beneﬁts), France in 1930, Greece in 1937, Spain in 1942, Italy in 1944, Belgium in 1944, Portugal in 1946, Sweden in 1946, Finland in 1964, Denmark in 1971. Early compulsory health insurance laws often built upon the basic structures provided by the voluntary mutual funds, leaving health insurance administration to the preexisting funds, but making membership for certain population groups compulsory.
The politics of mutual aid society and compulsory health insurance legislation are diverse. Many different types of political parties, spanning the political spectrum, introduced legislation intended to expand health insurance coverage. In France and Germany, conservatives proposed mutual aid society legislation against the opposition of liberals, whereas in Sweden and Switzerland, for example, the situation was just the reverse. German socialists opposed conservative Chancellor Bismarck’s compulsory health insurance, but, as they found they were able to use the sickness funds as an organizational resource, they later came to champion the insurance system. Indeed, it is precisely such alliances between political parties or social movements and the sickness funds that explain some of the partisan variation regarding statutory (that is, required by law) health insurance. Whereas in Germany, the territorial sickness funds (allgemeine Ortskrankenkassen) became a social democratic and union stronghold, in Belgium, the sickness funds were closely allied to the liberal, Catholic, and the socialist political parties. In the Netherlands, many sickness funds were started by doctors; in Sweden, they were tied to the Temperance (anti-alcohol) and Free Church (opposed to the State Church) movements, which, in turn, tended to be supporters of the liberal party, as were many Swiss sickness funds.
Some of the most important political conﬂicts surrounding nineteenth century and early twentieth century legislation concerned the issue of whether insurance coverage should be voluntary or compulsory, whether employers or workers or both should pay contributions and in what amounts, what proportion of the population—often deﬁned in terms of occupational groups—should be covered, and how to achieve portability of insurance beneﬁts. These issues tended to be of more direct concern to labor unions, employers, and the mutual aid societies than to doctors, and can thus perhaps be better viewed as ‘class’ issues than ‘professional’ issues. Not surprisingly, studies of this early period—which include contributions from history, sociology, and politics—have tended to be concerned with the causes and consequences of the rise of social insurance, and of the welfare state, more broadly. A key question has been whether the rise of working-class organizations and parties, as well as differences in working-class political mobilization—the degree to which members of the working-class actually voted for workers’ parties or joined trade unions, whether these organizations were divided by religious cleavages, and whether parties and trade unions cooperated—can explain the emergence of different programs of social protection in different European nations. A second line of questioning has been whether fear of class unrest is the sole motivation for government initiatives in this period, or whether states had other considerations related to their need for political legitimacy, particularly as parliamentary democracy came to be established in some nations but not in others.
1.3 The Interwar Period: Doctors S. Sickness Funds
As the growth of both voluntary and compulsory health insurance expanded the market for medical care in the ﬁrst third of the twentieth century, conﬂicts arose between doctors and both mutual aid societies and government insurance authorities. Whether public or private, the insurance carriers (those responsible for administering health insurance) sought to reduce the costs of medical treatment by restricting the fees that doctors could charge to insurance patients. These insurance conﬂicts coincided with doctors’ achievement of professional status, and encouraged the efforts underway to organize members of the profession into effective lobby associations (see below). Now health, politics had indeed become very much characterized by professional politics, and scholars studying twentieth-century health legislation have focused largely on the opinions, strategies, and success of organized medical professions in shaping government health programs to their liking.
For medical organizations, the key issue was to avoid becoming economically dependent on health insurance practice, and, especially, to maintain the status of doctors as independent practitioners in face of efforts to turn doctors into employees of the sickness funds. In Germany, the sickness funds relied on individual contracts with doctors and direct third party payment (i.e., the sickness funds paid the doctors directly) to keep fees low; only doctors that agreed to the conditions of the funds were admitted to insurance practice. This type of system is also known as a ‘closed panel’ or, in contemporary language, as a ‘preferred provider’ health insurance system. When the German system was to be extended to larger sectors of the population through the Reichversicherungsordnung (Imperial Insurance Code) of 1911, the two main doctors’ associations, the Leipziger Verband and the Deutsche Arzteverein, led a successful strike that culminated in the Berliner Abkommen (Berliner Accord) of 1913. This agreement established a bipartite board of representatives of both the medical profession and the sickness funds to govern entry to sickness fund practice, thereby ending the funds’ unilateral control of access to the insurance market.
In Germany, doctors fought within an established insurance system for ever better conditions of practice. Other medical associations looked to the German example, and fought for these measures from the start. In France and Switzerland, for example, a series of quite similar issues occupied health insurance debates from the beginning of the century through the 1960s. Doctors preferred a fee-for-service payment method (which allowed doctors to charge patients a separate fee for each service performed); they opposed third-party payment (tiers payant) and wished to receive payment directly from patients, leaving the patients to submit their bills to the sickness funds for reimbursement (tiers garant); medical associations were willing to negotiate collective fee schedules (lists of maximum fees, called Gebuhrenordnungen or Conventions) with insurance authorities, but they were opposed to individual contracts and asserted the individual discretion of physicians to charge more in difficult cases, or for all cases, if the physician was particularly well-known. Realizing that these conﬂicts were inherent in insurance practice, medical associations fought also against the extension of compulsory health insurance systems to entire populations, preferring instead that government or government subsidized insurance remain voluntary, or at least compulsory only for those with low incomes. Insurance carriers, on the other hand, did not wish to be responsible for undeﬁned and uncontrolled costs, and lobbied for government regulation of medical fees, and the extension of compulsory coverage.
1.4 The Postwar Period: National Health Systems
After the Second World War, most Western European governments massively expanded their health insurance coverage, many insuring entire populations as a right of citizenship. Not only health insurance, but the health system as a whole was the subject of reform efforts. In 1946, a Labour government introduced the British National Health Service (NHS) to provide healthcare to all citizens through publicly-owned hospitals and publicly-paid doctors. In order to overcome opposition from the British Medical Association—which largely represented the interests of the general practitioners—plans for salaried practice for outpatient care was dropped; instead general practitioners would be under contract to the NHS, and paid on a capitation basis (a yearly ﬂat-fee per patient enrolled with a particular doctor, regardless of how much or how little treatment is received), as they had been by the Approved Insurance Societies (Friendly Societies approved to carry national health insurance), since the National Insurance Act of 1911. Similar ideas of universal provision of healthcare through salaried hospital doctors and national health hospital plans were discussed in other nations as well, such as France (in 1944) and Sweden (in 1948), but failed due to medical opposition.
In a second wave of reform in the 1960s and 1970s, however, many European governments introduced controls on doctors’ fees, salaried service for hospital physicians, and national plans for health systems. In France, the decrees of May 12, 1960, promulgated by de Gaulle, established a system of departmental conventions (lists of maximum fees) for the control of doctors’ fees, which was replaced by a national convention in 1971. The Debre reform of 1958 established new mechanisms for hospital planning, created full-time salaried posts for hospital physicians, called for phasing out the private practice privileges of hospital chiefs of staff, and reformed medical education. In Sweden, a Social Democratic government banned private medical practice from public hospitals in 1969, and, in conjunction with the reform, hospital physicians agreed to be paid on a salary basis. In Italy, an agreement between the Italian Communist Party and the Christian Democrats established the Italian National Health Service (Servizio Sanitario Nazionale) in 1978. In 1986, the Spanish socialist government converted the national health insurance to a national health service, as well.
Even in nations where no formal changes in type of health system were made, efforts were made to introduce more effective measures of cost-containment, as well as hospital ﬁnancing and planning. The German Cost-Containment Law of 1977 (Krankenversicherungs-Kostendampfungsgesetz) provided for tripartite discussion of healthcare costs amongst representatives of government, sickness funds, and the medical profession, and for limits on the collective reimbursement made from the sickness funds to health insurance doctors. Subsequent reform efforts (most importantly in 1981, 1992, and 1997) have focused on further improvements in cost-containment and in extending these mechanisms to the hospital sector. In the Netherlands, too, legislation governing healthcare prices and hospital planning was introduced in 1982 that built upon a preexisting framework of negotiations between sickness funds and healthcare providers.
Since the 1990s, one can observe a shift in emphasis from direct government regulation of health prices and planning to experimentation with ‘market’ reforms. In the Netherlands, reforms have aimed to increase competition amongst insurance carriers. In the United Kingdom and Sweden, efforts have been made to introduce ‘internal markets’ and to increase ‘public competition,’ by creating mechanisms for the purchase of health services by local healthcare authorities and general practitioners (in the UK), and units of local government (in Sweden).
2. Health Governance
The power of the medical profession is a central theme not only in studies of government efforts to introduce and to reform public health programs, but also in research on the effectiveness of different health policies. Here, the theory of corporatism has proved to be a useful organizing principle for comparing government health care strategies and their effects. Proponents of a corporatist approach examine the ways in which medical doctors are organized in different countries. In Germany, for example, all doctors treating public insurance patients are required to belong to Associations of Sickness Fund Doctors, which in turn are represented by a peak association (Kassenarztliche Bundesvereinigung). They are thus not only highly organized, but organized into a single association. This legacy of the early days of German health insurance has allowed the government to leave many aspects of health policy—such as cost-containment measures—to arenas of collective negotiation between representatives of the sickness funds and the medical profession. Consequently, some policy analysts view negotiation—or governance through association—as an attractive alternative both to direct government intervention (‘State’) or purely economic mechanisms (‘Market’).
Scholars investigating the impact of government intervention in the medical area have also raised the question of the meaning of health reforms for the freedom and power of the medical profession. Is the right to a private practice an integral part of medical freedom—as many doctors’ associations have argued—or is the defense of the private market an outmoded vestige? Although many different aspects of the resources and privileges of doctors have been subsumed under the general term ‘power,’ investigations of the health area indicate that there may be several dimensions of medical power—not all of which vary together.
2.2 Theories Of The Professions
Theories of the professions—an offshoot of sociological research on stratiﬁcation—try to explain why some occupations are more privileged than others. Debate has concerned both the indicators of ‘privilege’ and its causes. The ‘functionalist’ approach views the essence of professionalism in the demonstration of the efficacy of a particular body of knowledge which generates public legitimacy for the autonomy of judgment of its practitioners. The ‘historicist’ approach, by contrast, argues that the emergence of a domain of knowledge and the association of that domain with an occupation grouping is an arbitrary and political process which can only be understood historically. The health ﬁeld has proved a fertile ground for this debate, because of the apparent unparalleled success of doctors in this ‘professionalization project.’ Western European studies have advanced the historicist argument, in particular, as research has detailed the great variation in the boundaries of professional knowledge, the organization of medicine, and the character of medical privilege across Europe.
Theories of the professions emphasize the process by which the medical profession became uniﬁed into a single, recognizable profession, and how members of this profession were able to upgrade their collective status, achieving recognition from both governments and the public for their claims to expertise. Debate continues, however, about the extent to which health expertise translates into success in the political arena. If one compares the success of medical professions in defending their right to set their own fees, and to an unregulated private practice—their ‘economic autonomy,’ so to speak—variation in Western Europe does not appear to be accounted for by variation in professional monopoly. In Switzerland, for example, government regulation of medical licensing, and even against medical quackery, has been relatively weak, yet the Swiss Medical Association has been highly successful in blocking the introduction of compulsory national health insurance and controls on doctors’ fees. An alternative explanation for such variation may lie in the properties of political institutions and their effects on political decision-making. Professional associations—in particularly those representing medical specialists—appear to be more universally successful in other areas of decision-making, however, such as individual decisions about treatment (clinical autonomy), or political debates about more purely ‘medical’ matters (such as funding of medical research or issues of medical malpractice). Whether an issue becomes deﬁned as ‘medical,’ ‘economic,’ or ‘social,’ however, is very much a matter of politics, and hence at the core of professional strategies.
2.3 States And Social Control
Following the lead of Norbert Elias and Michel Foucault—as well as, of course, the classical sociologists Durkheim and Weber—scholars have tried to reconstruct the meaning of health intervention for the relationship between state and society. The idea is to understand both why states become involved in regulating the health of citizens, and how beliefs associated with concepts like health, disease, and contagion are formed. The direction of analysis is not only from state to society, but examines how social practices involving health and hygiene—for example, the set of manners that demarcate the boundaries of appropriate public behavior—establish culturallyspeciﬁc concepts (also called ‘collective representations’) of state and society. In this way, the ‘politics of the body’ are thought to be construct images of the body politic, and hence to inﬂuence citizens’ attitudes and behaviors vis-a-vis social collectivities and political authorities. Consequently, work in this vein has interpreted health beliefs and health practices as part of a system of social and political domination. This type of ‘constructivist’ or ‘postmodern’ approach has often been adopted by proponents of a ‘gender’ approach. Here, ideas about the body, and the relationship of doctors to patients of both sexes are thought to play a role in establishing deﬁnitions of gender differences.
2.4 State Sovereignty
Finally, studies of healthcare governance have been part of a more general debate about the rise and future of the nation–state. Healthcare has been used as an example by which one can observe the origins and development of the institutions and mechanisms of governance peculiar to Western Europe. The complexities of governing the healthcare sector have provided empirical substance to a more general debate about whether classical state sovereignty is on the wane. The growth of the welfare state—precisely through the expansion of programs like national health insurance and national health services—has involved governments increasingly in negotiations with social actors—medical professions, labor unions, employers, and the like—thereby, in the eyes of some scholars, eroding states’ hard-won ‘internal sovereignty’ (the independence achieved by absolutist rulers from medieval corporations, estates, cities, or other subnational political actors). The international integration of national economies, and, especially, the regional integration of the Western European economies is, analogously, thought by some to threaten states’ ‘external sovereignty’ (the autonomy wrested by modern European nation–states from supranational authorities, such as the Catholic Church).
Whereas the problems of ‘domestic’ health politics and health governance have been investigated quite thoroughly, far less research has focused on the emerging problems of international or, especially, European health governance. It will be a challenge of future research to reﬁne the concepts and issues that have emerged from national contexts (albeit in comparative perspective)—such as the medical profession, professional autonomy, corporatism, national healthcare systems—in light of international cooperation and integration. Further, while a focus on Western Europe has promoted interdisciplinary research—with political scientists and historians, for example, using sociological theories of the professions as a departure for their own research—an equally pressing challenge will be to look beyond the borders of Western Europe for alternative approaches to the deﬁnition and study of ‘health.’ Lastly, as the study of health, like many policy areas, becomes increasingly inﬂuenced by an economics perspective—with market mechanisms favored by policy-makers and economic models of decision-making by social scientists—the remaining social and behavioral sciences will need to articulate compelling arguments for their continued contribution to the study of health.
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