Health in Western Europe Research Paper

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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

2.1    Corporatism

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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