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.