HEALTHDOX

The Paradox of Health State Futures

The HEATHDOX Project investigates the current political determinants and policy consequences of post-1989 European health reforms. The end of the cold war was a turning point for many European health systems, with many post-socialist transition countries privatizing their state-run health systems, and many West and Southern European health systems experimenting with new public management and other market-oriented health reforms. The aim of the project is to document the policy changes that have taken place over the course of the 1990s and through the first decade and a half of the 21st century, and to evaluate the consequences of these reforms for health care provision, especially how these changes in the public-private mix in health affect individual attitudes towards the health system. HEALTHDOX comprises seven country teams in six countries (Estonia, Germany, Ireland, the Netherlands, Portugal, Sweden) and has established a cooperative network comprised of researchers from all 28 European Union nations, as well as selected neighboring and accession candidate countries. Each researcher (some of whom are actually stakeholders in their health system) is preparing a data table that lists all reforms undertaken in their country, and codes the provisions of these policy changes. In addition, they are in the process of preparing narrative chapters that describe the politics of reform and their consequences. These chapters will be published as a reference work (Health Politics in Europe: A Handbook); the data set will be made open access within a year after its completion.

This combination of qualitative and quantitative data comprises the basis for the macro-, micro-, and multi-level analyses that we use to tackle the fundamental problem of controlling for endogeneity in analyzing welfare state attitudes. In brief, endogeneity refers to the chicken-and-egg problem of welfare state research: do we have generous welfare states in some countries because the public prefers generous welfare states? Or, do people prefer what they have been accustomed to, such that generous welfare states foster public support for a generous welfare state? By analyzing the impact of health reforms that alter the public-private mix in health, as well as individuals’ personal contact with specific sectors of the health system, we can begin to disentangle the causes of support for the welfare state and reveal dynamic trends than can shed light on health state futures. Preliminary results are intriguing. They show that moving from public to private insurance is associated with individuals becoming more politically conservative, and less supportive of government health care provision. Government announcements that they will introduce waiting-time guarantees result in as large an increase public satisfaction with the health system and support for government programs, as the actual implementation of these guarantees! Surprisingly, austerity politics after the financial crisis resulted in greater levels of public satisfaction with the health system in some countries. In nearly all countries studied thus far, substantial health privatization has taken place since the 1990s. But the viability of the public-private mix varies substantially. In some nations, the private sector provides for increased health capacities and supports the public system; in others, the entanglement of public and private is a pernicious mix. More sustained analysis is required to draw any hard conclusions, however. At the end of this study, HEALTHDOX will provide both scholars and policy-makers with insights about the functioning of European health systems, their popularity, and the political hot spots of the future.

Project Summary

The end of the cold war was a watershed for many European health systems, with most post-socialist transition countries privatizing their state-run health systems, and many Western and Southern European health systems experimenting with new public management and other market-oriented health reforms. The HEATHDOX Project takes stock of these developments by providing a thorough political analysis of the health reforms undertaken in 37 European countries since 1989. What were the problems of the health care system that governments hoped to redress through these reforms? What were their political motivations? How have their health systems been changed? And how have citizens reacted? Despite the common problems of health systems coping with growing demands as populations age, medical technology advances, and populations move more freely across borders, Europe’s health systems have shown rather large differences in their abilities to cope with these problems. Some key differences concern the degree to which the public is divided amongst different competing health programs such as public or private health care, and the extent to which sufficient tax financing is available to assure universality of coverage and access, as well as the success with which politicians and health ministers have been able to generate consensus for new policies. These factors divide the national health systems characterized by an optimistic and sustainable future outlook from those that suffer from division, conflict and inadequate provision of health care services. Furthermore, by relying on natural experiments and panel data, we have been able to demonstrate important causal impacts of health policies and health experiences on individual attitudes:

  • individuals that opt-out of public programs and purchase private insurance become more politically conservative, and less supportive of government health care provision
  • waiting-time guarantees result in increased public satisfaction with the health system and support for government programs, even before waiting times have actually decreased, possibly indicating that citizens approve of governments’ recognition of their health care needs as a good in itself
  • this ‘recognition effect’ wears off over time, however, unless service performance improvement is maintained
  • surprisingly, the positive effect of waiting-time guarantees on health care satisfaction is most pronounced among people in good health and with limited contact with health care rather than those with most contact with the health care system
  • austerity politics after the financial crisis resulted in greater levels of public satisfaction with the health system in some countries, depending upon partisanship and party framing
  • individuals in ‘Bismarckian’ health systems are more troubled by unfairness in health than those in ‘Beveridge’ systems
  • as health institutions in Eastern Europe converge towards those in Western Europe, so do people’s attitudes towards their health systems
  • foreign born respondents base their evaluations of their ‘adopted’ health system on comparisons with their country of origin, an effect that wears off over time, however

This research provides important insights for health governance and the political sustainability of health systems, as well as for the ability of European health systems to integrate newcomers to Europe and to the European Union.