Explaining Healthcare System Change

Explaining Healthcare System Change

Mirella Cacace, Ralf Goetze, Achim Schmid and Heinz Rothgang

CRC ‘Transformation of the State’ University of Bremen Germany

Email-contact: [email protected] [email protected] [email protected] [email protected]

Paper to be presented at the 4th International ESPAnet Expert Conference, University of Aalborg, 30th January -1st February 2008 Session 4: Changing health care syste ms: A matter of new ideas?

The paper is part of a collaborative research project on the changing role of the state in healthcare systems at the TranState Research Center 597. The project is based at the Center for Social Policy Research in Bremen and receives generous funding by the German Science Foundation (DFG). Director of the project is Prof. Dr. Heinz Rothgang.

Abstract The following contribution aims at providing the link between problem pressure and healthcare system change. It is part of a broader research project in which we have identified multiple convergence and common trends, especially with respect to the role of the state in healthcare systems, which also has led to the blurring of healthcare systems over the past forty years. With the proposed paper, we intend to lay out the theoretical groundwork for explaining these findings. Driving forces in the form of globalization, demographic change and advancements in medical technology cumulatively create problem pressure on healthcare systems. The direction and the timing of healthcare system transformation are structured by intervening variables, such as actors, their interests and perceptions. Yet the most influential factor is the healthcare systems themselves: their value systems, the associated veto points and organized interests as reflected in the specific system type. As healthcare system types vary, so do their adaptive responses to problem pressure (modified problem pressure hypothesis). It is this diversity which finally ends in convergence amongst systems taking up new directions of change, causing them to blur in their composite features and types.

1.

Introduction

In our paper, we outline our theoretical concept for explaining healthcare system change. We do this against the background of the information we gathered by qualitative and quantitative analysis of 23 OECD countries in conjunction with a detailed focus on the cases of Great Britain, Germany, and the United States. The cases are taken to represent ideal approximations of state-based, social insurance, and private healthcare system types, respectively. For our research, a multidimensional analytical framework is put forth that distinguishes between the financing, service provision, and regulation dimension of health care systems (Rothgang et al. 2005). Using the analogy of a house (Figure 1) that represents the healthcare system in totality, financing and service provision are the pillars. The regulation dimension represents the roof and therefore relates to the pillars by describing which aspect of the healthcare system, financing or service provision, is regulated. The foundation symbolizes the values, goals, and perceptions in healthcare. 1

1

This part of the house will not be explored here. See Frisina and Albrecht (forthcoming), for a comparative examination of values in the health care systems of Britain, Germany, and the US.

1

Figure 1: Financing, service provision and regulation of health care systems (Potential) Beneficiaries

Regulation Service Providers

Financing Agencies Service Provision

Financing

Goals/Values/Perceptions

Source: Rothgang et al. (2005)

As we will recapitulate in the first part of this contribution, our findings evidence convergence trends in the financing and in the regulation dimension. In the service provision dimension, common privatization and profitization trends have prevailed since the 1990s (Rothgang et al. forthcoming). We then continue by presenting our general explanatory model as a heuristic device in the second part of the paper. Amongst all factors contributing to the explanation of healthcare system change, we find that the specific healthcare system type and their respective functional requirements are crucial. We continue by describing the logic of the ‘modified problem pressure hypothesis,’ according to which, National Health Services (NHS), social insurance schemes (SIS) and market based, private insurance systems respond differently to global pressures as a result of their various institutional features. Finally, we make the claim for further research, as more case studies are needed in order to properly validate this hypothesis.

2.

The Changing Role of the State in Healthcare Systems

2.1 Essential Developments in Healthcare Financing The core question to be addressed in this section is how the role of the state in healthcare financing has changed after the end of the ‘golden era’ of the welfare state. Although OECD healthcare systems rely on their own specific funding- mix, neither the financing structure, nor funding levels have been static during the past decades. The basic trends across OECD countries can be summarized as level effects and corridor effects. While the former observe changes in average healthcare financing of OECD countries, corridor effects refer to measures of dispersion of healthcare financing across countries (Rothgang et al. 2006). In the following, we seek to demons trate that there is a pattern emerging across OECD countries best described as a process of convergence in healthcare financing. In order to evaluate the role of the state

2

in health financing, we use the public financing share, which subsumes tax financing and social insurance financing (cf. OECD 2004). Figure 2: Level and Convergence of the Public Financing Share 1970-2004 24%

76%

Mean share of public financing in % of THE (left Y-axis)

74%

22%

20%

72%

18%

Coeff. of variation of public financing in % of THE (right Y-axis) 70%

16%

68%

14%

66%

12%

64% 1970

Coeff. of var. in percentages deviation from the mean

Mean share of public financing in percentages of THE

78%

10% 1975

1980

1985

1990

1995

2000

Source: OECD 2007. Belgium is included from 1995 on.

Figure 2 shows the share of public financing in percentage of total health expenditure as the mean of 23 OECD nations and its coefficient of variation from 1970 to 2004. We can see that the mean public financing share increased considerably during the 1970s. From a low of 70 per cent in 1971, the public share mounted to over 76 per cent in 1979. In the beginning of the 1980s, however, the public share began to decline continuously. In 1999 on average about 73 per cent of health expenditure was fuelled by public sources. At the beginning of this millennium the privatization trend discontinued as the public share rose by about one percentage point to 74 per cent in 2004. Recent developments therefore presumably witness a ‘revival of the state’ in health financing. Even more interesting is the finding that healthcare systems have converged with respect to their funding mix. Over the whole time period, the coefficient of variation has declined as can be seen from the second graph in Figure 2. While in 1970 the coefficient of variation (i.e. the standard deviation from the mean relative to the mean public financing share) amounted to almost 22 per cent, it was only 15 per cent in 2004. Convergence occurs as countries with a low public financing share in the beginning of the observation period tended to increase the public financing share, while those countries which already displayed high values of public financing in 1970 rather turned to private financing. This pattern and the corresponding position of countries are exemplified in the fo llowing figure (Figure 3). 3

Figure 3: Correlation of the Public Financing Share in 1970 and the Average Annual Growth of the Public Financing Share between 1970 and 2004

Public exp. growth 1970-2004 (average rate)

1.0%

y = -0.0174x + 0.0141 2 R = 0.705

0.8% ICE

CHE

USA

0.6%

GRC

AUT POR

0.4%

JAP ESP

NLD

0.2%

FIN

AUS FRA

DEN UK

0.0% CAN

SWE GER

NZL

-0.2%

IRL

-0.4% -0.6% 30%

LUX

NOR

ITA

40%

50%

60%

70%

80%

90%

100%

Public exp. in % of THE in 1970

Source: OECD 2007. Belgium is excluded due to the lack of data.

Figure 3 shows the negative relationship between initial values of public financing share and its ave rage annual growth rate over the last decades. We can also identify countries which especially contribute to convergence in healthcare financing. The US, Greece and Switze rland, for example, show above average increases of the public financing share from low initial levels. Conversely, in several countries like Canada, Germany, New Zealand, Ireland, Italy and the Scandinavian countries, which all had above-average public financing shares in 1970, we can observe significant privatization trends. 2.2 Essential Developments in Healthcare Service Provision While internationally comparable time series on healthcare financing allow for a clear indication of the role of the state and its changes over time, there is no such common standard for the service provision dimension. In order to overcome this difficulty, we construct an indicator, i.e. the Public Provision Index (PPI), as a measure of public service provision. The PPI is constructed as a weighted mean of all sectors, i.e. the inpatient, outpatient, dental, and pha rmaceutical sector. As a formula for assessing the role of the state across all sectors, we exa mine changes in the public/private- mix within healthcare sectors and changes in the size of healthcare sectors (Schmid et al. forthcoming). In the inpatient sector, the public share is determined by the number of beds in public ownership. In the outpatient sectors (outpatient care, dental care and pharmaceuticals), the employment status of health personnel is used to delineate public from private provision. We define self-employed outpatient care providers as private (for-profit) entities, while healthcare personnel employed by the government are public. Figure 4 displays the changes in the PPI for 15 countries, which we selected according to data 4

availability. Restricted data availability is also the reason for a shorter observation period, starting in 1990 2 . Figure 4: The Public Service Provision Index (PPI) PPI = The Public Service Provision Index: 1990

∑a

i

⋅ Pi

i

1995

2000

Finland 84% 79% 78% Iceland 58% 62% Denmark 57% 57% 54% Norway 51% 50% Switzerland 43% 40% Austria 40% 38% Italy 38% 38% France 32% 31% 29% Australia 38% 34% 28% New Ze aland 34% 27% Germany 21% 20% 18% Japan 11% 11% Netherlands 7% 7% USA 11% 9% 7% ai = share of total health spending on sector i Pi = share of public service provision in sector i i = inpatient sector, outpatient sector, dental sector, pharmaceutical sector

2002/3 77% 64% 52% 47% 41% 39% 37% 30% 27% 26% 18% 7% 7%

Recent Trends 1990/95-2003 Minus 7% Plus 6% Minus 5% Minus 4% Minus 2 % Minus 1% Minus 2% Minus 2% Minus 11% Minus 8% Minus 3% 0 0 Minus 4%

Source: own depiction, compare (Schmid et al. forthcoming)

As a most general trend, we find that public service provision decreases in nearly all countries where data is available. In two cases, the public share is rather stable and in only one country, Iceland, public service provision is even increasing from an already high level. In the US, by contrast, a country where the role of the state in service provision is traditionally low, public involvement further decreased within the past 15 years. Although there is no evidence for convergence regarding the role of the state in healthcare delivery, we see a common privatization trend in the service provision dimensio n. Over almost all healthcare systems, the privatization trend is caused by two major factors. First, due to efficiency pressure and the requirement to provide care in the most suitable setting, the locus of care is shifted away from the inpatient to the outpatient sector (Getzen 2004; Tuohy et al. 2004). While the state traditio nally plays a greater role in the provision of hospital care, private providers prevail in the outpatient sector, most of them operating for-profit. Second, the state as a direct service provider is on the retreat, since governments in almost all healthcare systems divest their facilities. Mainly for-profit organizations buy up public hospi2

For some countries, longer time series are available. These suggest that privatization trends were set off in the 1980s in some countries (USA, Australia, Denmark), while other countries started to privatize services in the 1990s (Finland and Germany). By contrast the 1970s were in some countries also characterized by an expansion of public service provision (Finland).

5

tals in order to turn the industry into a profitable market segment. Besides privatization, therefore, there is also evidence for a ‘profitization’ in the delivery of services (Schmid et al. forthcoming). By calculating the PPI we measure material privatization, i.e. a change in ownership structure. There are, however, other forms of privatization (cf. Schneider and Tenbücken 2004). Privatization can also refer to the formal organization of healthcare providers (formal privatization). Furthe rmore, functional privatization describes the outsourcing of functions that used to be provided by public providers to private providers. Across healthcare systems, beneath material privatization, there is also evidence for formal and functional privatization. We will come back to these issues later, when we show how distinct types of healthcare systems respond differently to global problem pressure. 2.3 The Blurring of Healthcare Systems in the Regulation Dimension For the first two dimensions, we measured the role of the state directly as the public share in financing and service provision respectively. Regarding the third aspect of the role of the state, namely the regulation dimension, the research design was amended to three qualitative case studies. We chose the cases of Britain, Germany and the United States as these countries most closely resembled the respective ideal types of a state- led National Health Service (NHS), a social insurance scheme (SIS), and a private health insurance system in the beginning of our observation period in the 1970s (Boscheck 2005; Giaimo 2002; Giaimo and Manow 1999; Rothgang 2006). Our main finding is that these healthcare systems incorporate elements that are non system-specific, which led to a considerable hybridization of healthcare systems (Rothgang et al. forthcoming). As healthcare systems ‘blur’ by incorporating elements from one another, mixed types emerge. The convergence hypothesis in the regulation dimension therefore suggests that healthcare system became more similar as they adopt instruments and structures from each other. Within this process, the diffusion of instruments and institutional learning plays a role (Gilardi et al. 2005; Wilsford 1995). Healthcare regulation refers to the fundamental relationships between the three main actors in healthcare systems, i.e. the service providers, the financing bodies, and the potential beneficiaries. For our analysis, we focus on the structural features of regulation by examining the actors (thereby addressing the question, who regulates the healthcare system?) and the mode of interaction describing the mechanism by which the system is co-ordinated (Rothgang 2006; Tuohy 1999: 7). As concerns actors, we refer to three specific kinds that are relevant in the regulation of healthcare systems, namely the state, corporate actors (as e.g. the associa6

tions of sickness funds or providers), and private market participants. With regard to the specific interactions taking place between actors, we identify three basic modes of regulation3 : (1) the exertion of hierarchical control (2) the engagement in bargaining processes where contract partners interact on equal footing and (3) the condition of competition which implies rivalry between individuals or groups. The purest types of regulatory structures can be said to result from combining actors and modes of interaction in a most intuitive way – that is, by linking state with hierarchy (as in national health services), collective actors with bargaining elements (as in social insurances schemes), and market actors with competition (as in private healthcare systems). In the beginning of our observation period in the 1970s, Britain, Germany and the United States can be said to be the most ideal representations of these pure types, as displayed in large print by the diagona l of Figure 5. Yet, triggered by the need to react to global problem pressure (to be discussed), to which transformations of regulatory structures did changes lead? By way of summary, the following Figure 5 displays the changes we found in the regulatory structures of the healthcare systems of Britain, Germany and the United States. These changes may be the result of purposeful reform policies, but even more plausibly, a consequence of what Hacker (2004) calls ‘drift’ or ‘conversion’ 4 (cf. also Thelen 2003). Figure 5: The changing regulatory structures in Britain, Germany and the United States

Source: Own depiction

Beginning with the case of the British NHS, we find an example of a state- led healthcare system that has introduced market elements to improve efficiency. Furthermore, many essential healthcare decisions have been handed over from the central government to regional and local bodies (Lewis et al. 2006; Osborne and Gaebler 1992). Interestingly, the prevalence of market mechanisms in the British healthcare system has been accompanied by a stronger state involvement as indicated for example by the increasing role of the state in the regulation of ser3

We would like to emphasize here that we use the term regulation to refer to all three modes of interaction defined here. 4 While policy conversion denotes the decentralized adjustment process on the part of actors empowered under the existing regime, policy drift implies transformation of systems due to the failure to update policies to changing circumstances (Hacker 2004: 722).

7

vice providers (Giaimo and Manow 1999: 972; Grimmeisen forthcoming; Hacker 2004; Klein 1996: 241). This finding clearly is at odds with the view that regulation is a zero-sum game, i.e. that an increase in market competition necessarily leads to a loss of hierarchical state regulation. We emphasizes, in contrast, that the growing role of market competition rather strengthens than weakens state authority, especially as these reforms, once initiated, required further state intervention (Hacker 2004: 712). In the case of the German social insurance system, the dominant structure of mutual selfregulation through corporate actors has largely been preserved if not expanded in the first two decades of our observation period (Alber 1992; Döhler and Manow-Borgwardt 1992; Giaimo and Manow 1999: 978). These developments, however, have to some extent been offset by the introduction of competition between sickness funds in 1992, as well as the introduction of Diagnosis Related Groups (DRG)-based5 remuneration in 2003, which have afforded a greater role to the state in the regulation of healthcare policy and, at the same time, to the market. That is, although there is a continued reliance on corporatist self-regulation, Germany now makes room for public (state) and private (market) actors in its healthcare system, thereby squeezing the traditional system of self-regulation in between (Rothgang et al. forthcoming). Finally, with regard to the private healthcare system of the US, hierarchical state regulation rose significantly as a result of the creation of the public programmes Medicare and Medicaid. Beyond this, the federal government uses market incentives as it employs public funds to subsidize employer-sponsored private insurance (Hacker 2002). Yet within the realm of private insurance, hierarchical state regulation remained weak, paving the way for considerable policy conversion (Hacker 2004: 721; Stone 2000). Thus at the same time, private insurance experienced the emergence of managed care proliferating quickly from the 1980s on, which, although purely private by nature, has given way to a series of hierarchical arrangements {Rothgang, forthcoming #3086}. As a consequence of the backlash against managed care, hierarchical regulation of providers and patients was amended by bargaining elements. Due to the spill-over of managed care to the public programs, and as private insurers adopt remuneration methods from the Medicare program, the boundaries between the public and the private blurred (Cacace 2007). Thus in all three healthcare systems, the regulatory structure has altered profoundly. Although each system continues to retain its basic character, i.e. state hierarchy in Britain, corporatist self-regulation in Germany, and market competition in the US, we find more complex 5

DRG-based payment systems are a reimbursement method for inpatient treatments. They are calculated prospectively by splitting all illnesses into groups and estimating costs per case within each group.

8

regulatory structures in which the dominant regulation mechanism is amended by those mechanisms originally lacking. To sum up these results shortly, healthcare systems in general once differed largely with regards to spending patterns, the mode of service delivery and their regulatory structures. The developments we observed can be understood as convergence (primarily financing dimension), common privatization trends (service provision) and a blurring of healthcare systems (regulatory dimension). On the basis of the single case studies, we find different movements which correspond to the specific system types in financing, service provision, and regulation of healthcare systems.

3.

Explaining Healthcare System Change

In order to explain these phenomena, it is hypothesized that healthcare systems share a common source of problem pressure which forces them to induce change. If this is true, so the standard argument of the “functionalist” sort, we should witness a uniform reform path in all industrialized countries (Hacker 1998: 60f., Abel-Smith and Mossialos 1994, cf. also Gaimo and Manow 1999). Far away from this standard theory, we find that the chosen trajectories of reform vary considerably between the distinct types of healthcare systems. The direction of change is ultimately subject to the particularities of individual system types (modified problem pressure hypothesis). The modified problem pressure hypothesis suggests that, as system types vary so too do their adaptive responses to problem pressure. It is this diversity which finally ends in convergence amongst systems. In the following section, we start by presenting a general explanatory model for healthcare system change. We continue with a system-type specific account of the interplay between the driving forces and interve ning variables. 3.1 The General Explanatory Model In order to structure our argument, we propose a general model of healthcare system change, which serves as a heuristic device (see Figure 6). Accordingly, the explanatory model addresses the interplay of specific driving forces, which cumulatively create problem pressure on healthcare systems. This system stressor can then be seen to interact with the intervening variable. Intervening variables structure change by veering systems toward a specific direction and by setting the pace; thus accelerating or retarding, and even temporarily arresting transformation. The most crucial factor amongst the intervening variables is the healthcare systems themselves: their value systems, the associated veto points, and organized interests, which of course are also part of the broader political-economic system. In line with the modified problem pressure hypothesis, it is both the nature and degree of the healthcare system’s 9

problem pressure, subsequently mediated by the component factors of the system itself, which can be said to define the direction of healthcare system transformation observed (dependent variable). Figure 6: General Explanatory Model Driving Forces

Intervening Variables

Healthcare System Transformation

Political-economic System

INSTITUTIONAL FORCES: § Europeanization § NAFTA, WTO, WHO

Value System

Problem Pressure

M ATERIAL FORCES: § Globalization § Medical Technological Progress § Demographic Change

IDEATIONAL FORCES: § Individualization

Ideas and Perceptions Healthcare System Type

Actors

§ Convergence § Common Privatization Trends § Blurring of Healthcare Systems

Political Institutional FraPolitical-economic System meworks

Source: own depiction

To start with the driving forces, we distinguish between material (e.g. globalization, medical/technological progress, demographic change), institutional (e.g. Europeanization), and ideational forces (individualization). Individualization trends have two major consequences as, on the one hand, changing life patterns demand new forms of risk protection, while, on the other hand, increasingly informed and self-conscious patients successfully demand the responsiveness of healthcare services. Without going into too much detail about the mechanisms how these forces act in an isolated manner, it can be said that especially demographic change and medical progress tend to increase demand for scarce resources while globalization and partially also Europeanization set limits on their availability. For the time being, however, we will take these factors as exogenous arguing that their cumulative effects create efficiency pressure on healthcare systems (Giaimo and Manow 1999: 967; Henke and Reimers 2006; Tuohy 1999). As a consequence, in addition to the cost containment debate of the 1970s, efficiency is the catchwo rd in the political debate of the 1990s. In all healthcare systems we observed, the need for restructuring translated into greater pressure to regulate the relationship between the three major actors, i.e. patients, service providers, and financing bodies (Hacker 2004; Wilsford 1995).

10

A widely held belief is that problem pressure, triggered by the driving forces described above, necessarily leads to a privatization of social risks, to the introduction of market competition, and to a retreat of the state over all healthcare systems of the OECD world. 6 Yet in our own empirical data, we find that common privatization trends are solely observed in the service provision dimension. Privatization tendencies, therefore, represent only part of the bigger story. Even more interestingly, the efficiency requirement has also led to the phenomenon of convergence in the financing dimension and to a blurring of healthcare systems’ regulatory structures. The question, why do mixed-types of healthcare systems emerge, therefore, leads to our core theme, the modified problem pressure hypothesis. 3.2 The Modified Problem Pressure Hypothesis: Why do Mixed-Types of Healthcare Systems Emerge? Our argument relates to a line of socio-economic development theories that view healthcare systems as a mechanism for meeting new demands (e.g. Abel-Smith and Mossialos 1994; Field 1999; Mechanic and Rochefort 1996). Yet, this theoretical batch has so far neglected that healthcare system types themselves, differing crucially with respect to their financing, service provision, and regulation dimensions, are the pivotal intervening variable: that is, healthcare systems tunnel and thereby qualify the nature and direction in which change will take place as a result of problem pressure. The modified problem pressure hypothesis, therefore, emphasizes that problem pressure is mediated by the component factors of the system itself. Therefore different lines of adaptation emerge, depending upon the specific healthcare system type the observed countries resemble. In a somewhat stylized manner, we therefore exemplify the changes for (1) state- led NHS systems, (2) social insurance schemes, and (3) private healthcare systems. As system types vary, so too do their adaptive responses to problem pressure. It is this diversity which finally ends in convergence amongst systems taking up new directions of change, causing them to blur in their composite features and types. 3.3 State-led NHS Systems In this section we focus on explaining the blurring of healthcare systems in state- led NHStype healthcare systems. General features of NHS systems include the delivery of healthcare on the basis of social citizenship. Service delivery tends to be universal in the sense of unive rsal coverage and ideally also in the sense of a full range of health services provided for free at the point of delivery. Consequentially, as services are granted on the basis of citizenship, they are typically financed through taxes. Health service delivery is characterized by the dominance of public provision, i.e. state-owned hospitals as the dominant providers in the inpatient 6

See Giaimo and Manow (1999) for a general critique.

11

sector and public employees in the outpatient sectors. Moreover, the relations between financing institutions, service providers and (potential) beneficiaries/patients are mainly regulated through state hierarchy. Among our sample, the Nordic countries (Denmark, Finland, Iceland, Norway and Sweden), Australia, Canada, Ireland, New Zealand and the UK, as well as Italy, Spain and Portugal have been classified as NHS countries. These countries most closely fulfil the criteria of tax financing, public provision and hierarchical control as the dominant mode of regulation at the beginning of our observation period; i.e. in the 1970s after the consolidation of healthcare systems and before economic shocks severely affected the ‘golden age’ of the welfare state. Nevertheless, this large group of NHS countries is heterogeneous and some countries significantly deviate from the ideal type description. In Australia and Canada, for example, the public system does not cover a full range of health services and leaves the delivery of such services to the private market (Hall and Savage 2005; Marchildon 2006). Also in Portugal people are required to complement public health services with private insurance or out-of pocket payments. Canada is also outstanding since healthcare is mainly delivered by private nonprofit hospitals and self-employed physicians (Marchildon 2006). Except for Finland, Iceland, Norway, and Sweden, the outpatient, dental and pharmaceutical sectors are traditionally cha racterized by private providers, i.e. self-employed doctors and business pharmacies (Schmid et al. forthcoming). NHS systems, as compared to private or social health insurance schemes, are successful in cost-containment, but tend to develop specific malfunctions such as long waiting lists for certain treatments, insufficient investment in healthcare facilities, poor responsiveness and low productivity of providers. These problems are related to budget cuts which entail forms of rationing, but can also be more generally related to the idea of ‘state failure,’ which assumes that state-organized healthcare may guarantee equal access to services but fails to provide services efficiently (Scott 2001: 29). Our argument to explain convergence and the eme rgence of mixed type healthcare systems suggests that increasing problem pressure translates into the need to produce healthcare services more efficiently. In state- led NHS systems this need mainly translates into remedies to ‘state failure’ by recourse to non-state based or market and societal alternatives in health care. The developments in state- led systems with respect to the role of the state in the three dimensions of healthcare can be summarized as follows. First and foremost, the role of private

12

healthcare financing has increased 7 . Secondly, service provision has been privatized in various ways. The PPI presented above shows a decline in public provision in most countries. Moreover, formal and functional privatization have been observed as public hospitals have adopted private legal forms and outsourced activities to private corporations. Thirdly, some NHS (England, Sweden, and New Zealand) systems experienced blurring as they implemented competition as a mode of regulation which is rather typical for market-based healthcare systems (see Donaldson et al. 2005: 23). However, the implementation of marketoriented reforms does not necessarily mean a loss of state authority, since markets ‘need’ to be regulated. Therefore market-oriented reforms have gone hand in hand with intensified state hierarchy, in particular in England. Since globalization sets limits to tax increases and public spending, NHS systems experience the need to contain healthcare costs. Indeed, NHS systems have been successful with respect to curbing health spending, since budget cuts can be implemented comparatively easily through state authority (Alber 1989). On average, NHS health systems tend to spend less on total health expenditures than social insurance or market-based healthcare systems (Nixon 2002). The increasing salience of private financing in state- led systems may be simply provoked by the fact public health spending has been curbed because of budgetary restraints (Tuohy et al. 2004). Private spending growth can also be linked to efficiency in two ways. The failure of NHS systems to provide high standards of treatment and the existence of undue waiting times provides incentives to choose private suppliers for those who can afford it. Hence, the rise of private financing reveals dissatisfaction with the public system (Klein 2005: 47). In particular, in combination with ‘individualization’ trends in the sense of growing consumer expectations people are likely to turn to private alternatives. However, the rise of private financing may also reflect attempts to avoid excessive demand related to the fact that health services are ideally free at the point of delivery. Co-payments can be used to control demand or to steer demand away from expensive services to cheaper primary care. The latter can for example be observed in Scandinavian countries and Italy (Anell 2005; France et al. 2005; Pedersen 2005). It has to be considered though, that there are limits to privatization because of deeply entrenched values of guaranteeing free access to health services independent from the ability to pay. Hence, the use of co-payments as well as underfunding health systems may involve high 7

There are some exceptions: Portugal, which may be considered as a NHS-late-comer, has increased public financing from about 50 per cent in the mid 1980s to some 73 per cent in 2004. The UK and Ireland have increased public spending recently and both reversed privatization trends experienced particularly in the 1980s and 1990s (OECD 2007).

13

political costs. The UK may serve as an example for a country where public financing has increased massively from 2003 on, after a long years of continuous decline of the public financing share (OECD 2007). Typically, health service delivery in state-led systems is dominated by public providers. However, the PPI presented above reveals that public provision in the beginning of the 1990s ranged from about 40 per cent to 84 per cent in NHS systems. The PPI indicates that on ave rage public provision is more important than in non-NHS countries, but there is a lot of heterogeneity among NSH systems. Particularly, in the outpatient sector private providers are working on contract for the public system, while the hospital sector is dominated by publicly owned facilities. 8 Traditio nally, in most NHS systems hospitals have been integrated into the public administrative system and managed in a command and control style (Busse et al. 2002). Here again the ‘state failure’ thesis has been brought forward. Since public authorities cover deficits and absorb profits, a lack of incentives to provide cost-effective services is assumed. Moreover, political institutions may seek legitimization through the supply of healthcare facilities and provoke excess supply and therefore hamper efficient provision (Wörz 2007). As a result, we can observe a common trend of granting hospitals more autonomy and diverse forms of privatization. A first step has often been functional privatization, particularly the outsourcing of non-clinical services to private corporations. Less often, health related functions and hospital management have been outsourced (Maarse 2004: 181). Since these activities are now performed by for-profit companies, functional privatization also means profitization of activities which used to be in the hands of public hospitals. The trend to abolish command and control management and to grant more autonomy to hospitals goes hand in hand with formal privatization (Busse et al. 2002). This means, hospitals adopt private legal forms and private management structures while they remain in public hands (Klein 2005; Pedersen 2005). The sale of hospitals to private owners, however, appears to be rather ma rginal in NHS countries. More often private providers have been strengthened implicitly as resources have been steered towards the outpatient sector, where private providers play an important role (Schmid et al. forthcoming).

8

The exception is Canada where private non-profit ownership is the dominant form of ownership (Marchildon 2006). Service delivery in Canada, therefore, is not in line with the typical NHS.

14

The seesaw effect of market oriented reforms In the regulation dimension the most influential change which contributes to a blurring of healthcare systems has been the introduction of a purchaser-provider split. Several NHS systems such as England, Finland, Italy, Sweden, and Spain have established a purchaserprovider split though in some cases limited to certain areas (Sweden, Spain) (Figueras et al. 2002). Probably the most comprehensive reform steps that have been taken by the English NHS were the creation of ‘internal markets’. Thereby competition has been introduced as a mode of regulation in a health system, which is dominated by state control (Grimmeisen forthcoming, Giaimo and Manow 1999: 972). As an effect of the NHS and Community Care Act of 1990 purchasers of healthcare services were separated from providers. Health authorities did not provide services as hospital owners but had to purchase services from independent hospitals. At the same time GPs became GP fundholders as they received a budget for their patients, which they could allocate to specialist care in hospitals or primary care (Fattore 1999). Planning was replaced by purchasing and linked to the hope that NHS resources for the first time since 1948 would follow the individual patient thereby increasing the responsiveness and efficiency of the NHS. Despite rhetoric of ending internal markets, successive reforms of the Labour government maintained the purchaser-provider split (Klein 2005: 53). After a series of organizational reforms now Primary Care Trusts (as the successor organization of GP fundholders and Primary Care Groups) hold the budget for patients which amounts to 75 per cent of NHS the budget and may purchase a full range of services including primary care and community care (Mason and Smith 2006). Competition gained ground slowly, but has intensified since foundation trust hospitals are allowed to keep profits (Cacace et al. 2008: 19f). The introduction of market mechanisms however provoked new state interventions. During the implementation of the purchaser-provider split, hospitals ran into difficulties because of massive problems with calculating costs and contract models with purchasers. In order to support hospitals and competition cost calculation was standardized by NHS Executives through Health Care Resource Groups (an equivalent to Diagnosis Related Groups) (Grimmeisen forthcoming). Thus, hospital remuneration exemplifies a seesaw effect as the state is forced to regulate competition in order to guarantee the functioning of markets.

15

3.4 Social Insurance Systems Social insurance systems (SIS) form the second largest group 9 in our sample of 23 OECD countries. The system logic is characterized by corporatist self-regulation based on bargaining between sickness funds and provider associations (Jacobs and Goddard 2000: 15; Rothgang et al. 2005: 191). On the financing side, wage-related contributions play a dominant role. With regard to the health service delivery, inpatient care mainly relies on public or private nonprofit providers, whereas the other healthcare sectors (out-patient, dental, pharmaceuticals) are dominated by private for-profit providers. Social insurance schemes usually cover a large part but not the entire population. Although insurance in general is mandatory, especially the self-employed, civil servants, and high- income employees have an exit-option or are even excluded from the scheme. These population groups therefore often have private insurance or are included in special schemes (Carrin and James 2004: 13). Regarding the role of the state in SIS we observe the following trends: the funding mix remains relatively stable, while we find a profitization trend in service provision and an erosion of corporatist self-regulation. In the past three decades, bargaining between corporate actors has been challenged by other modes of regulation, namely by state hierarchy and ma rket competition. This change in the regulation dimension contributes to the blurring of healthcare regimes. In the following, we develop the approach to explain the blurring and profitization process in SIS. Ideally, collective agreements between corporate actors (mainly sickness funds and provider associations) provide stability and minimize transaction costs in comparison to hierarchical or competitive modes of regulation (Moe 1990: 230; Scharpf 1989: 158). Collective agreements may therefore help to avoid drawbacks on the state and markets at the same time. First of all, collective agreements may prove to be superior to state hierarchy since they rely on corporate actors’ professional expertise. Furthermore agreement-based decisions provoke less resistance in policy implementation (Moe 1990: 227; Visser and Hemerijck 1997). The bargaining relationships in social insurance systems most likely lead to a common solution, as the cost of exiting the process is high. In contrast to market processes, high exit costs force corporate actors to use their ‘voice’ option10 which is more appropriate in achieving efficient results in highly asymmetrical healthcare markets (Hirschman 1970; Rice 1998).

9

This group consists of countries with a dominating role of a social insurance scheme: Austria (AUT), Belgium (BEL), France (FRA), Germany (GER), Japan (JPN), Luxembourg (LUX), the Netherlands (NLD) and since 1996 also Switzerland (CHE). 10 Exit and voice refer to Hirschman’s concept, according to which there are two different modes to show approval or disapproval to a given policy option, bargaining process etc. The voice-option means to influence the

16

Sickness funds and provider associations operating within SIS ideally not only promote selfish interests, but take into account general wellbeing as well. Therefore, even the contributors and patients (as poorly organized groups) may have an allotted, however limited, position in the bargaining process (Olson 1965). In this case, well organized sickness fund and provider associations act as representatives of contributors and patients – even more, since corporate actors seek to avoid state interventions. Hence, the ‘shadow of hierarchy’ (Scharpf 1993) prevents rent seeking behavior of the corporate actors. In a nutshell, corporatist self- regulation ideally may guarantee efficient regulation and serve the ge neral interests. Blurring – the erosion of corporatist self-regulation In contrast to the ideal model described above, this mode of regulation may also be associated with serious deficiencies. On the one hand, collective bargaining is vulnerable to deadlock when the atmosphere between the corporatist actors changes from cooperation to confrontation due to their mutual veto position (Scharpf 1989: 171). A common label for this blockage is ‘institutional sclerosis’ (Olson 1982: 78). On the other hand, even with an ongoing cooperation between the corporatist actors, the results may only reflect their particular, but not ge neral interests. This often occurs if they anticipate the shadow of hierarchy as not threatening enough to alter their behavior. Thus, besides the ‘ideal’ functional model, there is also a dysfunctional model of corporatist self-regulation. Adding a binary level of institutional integration of the corporate actors to the functional and dysfunctional scenario for corporative support produces a four field matrix (see Figure 7). ‘Innovative corporatism’ reflected the system type’s earliest phase, before the introduction of statutory health insurance, when poorly integrated friendly societies first established their responsibility to provide healthcare. In the following phase of ‘open corporatism’ the state empowered the sickness funds and provider associations to run and expand the healt hcare system. After the oil price shocks of the 1970s, differences between state and corporate interests occurred, leading to an increasingly ‘immobile corporatism’. In this situation we observe two combinable solutions to overcome the dysfunctional deadlock: the shadow of hierarchy forces a step back to a supportive ‘open corporatism’ or it strikes back which leads to an ‘eroding corporatism’. The latter implies a blurring effect because hierarchical or competitive modes of regulation gain greater relative and/or absolute power.

results by participation, e.g. through voting. The exit-strategy, in contrast, implies that individuals that disagree drop out of the system (Hirschman 1970).

17

Figure 7: Functional types of corporatism

Source: own figure on the basis of (Visser and Hemerijck 1997)

We conclude that the decreasing role of corporatist self- regulation is mainly a reaction to selfinflicted steering failures. In social insurance systems these led to poor performance regarding cost-containment and a lack of cost-effectiveness. With regard to cost-containment, collective bargaining seems to be less effective than the central budget planning of NHS systems. In 2005, five of the six OECD countries, which spent the highest share of their GDP for healthcare, were dominated by a social insurance scheme, while the vast majority of NHS systems were below the OECD-23 average (OECD 2007). As mentioned previously, the main reason for this effect seems to be the rent seeking behavior of corporatist actors. Poorly organized groups like those of contribution payers have neither voice nor exit options to control their agents. If problem solving capacity of the selfregulating social insurance systems is exhausted, the government is forced to intervene. For example, the state can improve conditions for competition in the insurer or provider market. Empirically, this process started with the abolition of fund assignation which leads to market competition between the sickness funds (Rothgang et al. forthcoming). Although employees are still obliged to buy insurance, they could select their favorite fund thereby enhancing the accountability of sickness funds for their members’ interests (Sappington 1991: 57). We find evidence for this in the German healthcare system after 1996 and in the Netherlands after 1989. In the Netherlands, the increasing importance of flat-rate contributions even reinforced the competitive character of the reforms (den Exter et al. 2004: 41). A considerable side-effect of competition between sickness funds is the incentive for risk selection (Cacace et al. 2008: 14). A few insurers, which have developed successful methods for cream-skimming, can offer low contribution rates, while the rest has to demand very high rates. In nearly all social insurance systems, the state reacted to this adverse result of market competition with the hierarchical introduction of risk compensation schemes (Greß et al. 2002: 251; Jacobs and Goddard 2000: 111; Schut 1995). As the sickness funds needed a different, more functional, instrument 18

for price differentiation, the government started to cutback the collective bargaining with the introduction of selective contracts (Cacace et al. 2008: 14). We find evidence for this spillover effect of competition to the provider market in Germany and in the Netherlands. The new options for selective contracting introduced also competitive elements in the provider market (Böckmann 2007: 22; Greß et al. 2006: 298; Maarse and Bartholomée 2007: 77). In short, we identify a seesaw effect between market competition and state hierarchy, which squeezes the former corporatist arrangement. Moreover, collective contracting between umbrella organizations of sickness funds and provider associations became more strongly affected by hierarchical regulation. The state intervened in the reimbursement of healthcare providers by introducing mechanisms of direct price control. Since the early 1990s, nearly all social insurance systems ha ve introduced fixed or reference prices in their pharmaceutical markets (Ess et al. 2003; Mrazek 2002: 456). The in-patient sector was also affected by an increase of hierarchical price regulation. In many SIS the reimbursement of hospital services has changed (or changes currently) from a retrospective to a prospective payment system by using diagnosis related groups (AUT, GER, FRA, NLD, and CHE). Another reason for increasing state hierarchy in SIS seems to be nearly uncontrolled expansion of the benefit package. This process is driven by the strong position of the provider associations in the bargaining process. As health expenditure grew faster than the GDP, the state in most social insurance systems reacted by cutting back benefits and with the foundation of institutions for health technology assessment, both of which represent hierarchical modes of regulation (AUT, BEL, FRA, GER, and NLD). Due to the fact that contributions in social insurance systems mainly are earnings-related (and do not include capital incomes) social insurance system face a twofold problem. First, the income base is eroding for several reasons, while healthcare expenditures increase due to technological progress and demographic change. Second, system-specific pressure emerges as insurance contributions are part of the labour cost. Social insurance systems, therefore, are especially vulnerable to global comp etitive pressure (Ferrera et al. 2001: 168). The income base is eroding as payroll taxes constitute a decreasing share of the overall income of an economy (Jacobs and Goddard 2000: 113). Moreover, a shift can be observed within the labour market, namely from fulltime employment to part-time work and to jobs that are not liable to insurance deductions (OECD 2007). In addition, low birth rates and increasing life expectancy affect the ratio between net contributing employment force and net receiving pensioners (Kanavos and Yfantopoulus 1999: 160). 19

Taking these problems together there is a great incentive for SIS to decrease the income dependency of the financing system to improve the economic competitiveness. On the one hand, this can be done by increasing the share of taxes or private sources. In case of private out-of-pocket expenditure we find small evidence for this strategy in Germany and the Netherlands since the mid 1990s (OECD 2007). Cost-sharing 11 increased especially for pharmaceuticals and for out-patient visits. On the other hand, the social insurance contribution itself can be transformed from income-dependent to flat-rate contributions. This fits to the recent reform policy in SIS. Based on the recommendations of the Dekker Commission (1987) the Netherlands introduced in 1989 a marginal flat-rate contribution (den Exter et al. 2004: 41). After the major reform of 2006 the flat-rate contribution covers now almost half of total expenditures for acute care (Greß et al. 2007: 63). The post-Fordist society with its volatile work and family life cycles also challenges the responsiveness of social insurance schemes. As an increasing part of the population drops out of the protective realm of social insurance schemes, a small but increasing number of the population is uninsured and has to draw on social assistance in case of emergency (Busse and Riesberg 2004: 15). As a result of this process, Germany and the Netherlands started to introduce a mandate to insure for the entire population, combined with an obligation to contract for some or even all sickness funds. In service provision, social insurance systems rely on a mix of public, private non-profit and private for-profit providers. Whereas private for-profit providers control out-patient, dental and pharmaceutical sectors, public or private non-profit providers dominate in-patient care (Eeckloo et al. 2007: 79). Over the past three decades we observe a constant profitization trend in the hospital sector. The relative number of non-profit hospital beds has decreased in most SIS (Schmid et al. forthcoming) For example, the share of German for-profit ho spital beds increased in the time period between the reunification and 2004 from 4 to 11 percent while the share of public beds decreased from 61.4 to 52.3 percent (Wörz 2007: 127). The explanation for these trends is mainly based on the financial austerity of SIS since the oil crisis of the 1970s which limited the capacity of public funds to run own hospitals or support investments in non-profit hospitals. Selling public ho spitals to for-profit providers has

11

Major changes in cost-sharing requirements in Germany are related with the Gesundheitsreformgesetz (1992) and the Gesundheitsmodernisierungsgesetz (2004). In the Netherlands the Algemene Eigen Bijdrageregeling (1996; 1998 revised) is highly relevant with respect to that issue.

20

two major advantages 12 for local or state authorities. Public institutions receive cash and reduce future costs at the same time. As individualization is a common trend, membership in corporative organizations (churches, charity societies, unions) is decreasing (Houtman and Aupers 2007: 314; Visser 2006: 45). Yet, these organizations mainly run private non-profit hospitals in social insurance systems, thus, besides public hospitals, also private non-profit facilities have been affected by financial austerity. This erodes three major resources of non-profit hospitals: voluntary work, member fees and donations. As providing healthcare is mostly not the core business of these corporative institutions (except charity societies) they may also have an incentive to sell their hospitals and use the savings for their key concerns interest In conclusion, the classical corporatist self-regulation of SIS has not proven its capability to solve common problems of OECD healthcare systems: cost-containment and costeffectiveness. As a consequence, the state intervened by hierarchical regulation. Another strategy was to introduce competitive market elements, which in turn also implied more government intervention. Yet the adverse effects of market competition triggered the need for further hierarchical state regulation (seesaw effect). Taken together, these effects led to the observed erosion of corporatist self-regulation and to the blurring of social insurance systems. In service provision we also choose a functional argument to explain the profitization trend. Over the past decades, public and private non-profit actors experienced a constant erosion of their financing base which has led to the divesture of inpatient care facilities. 3.5 Private Insurance System The system logic of a private healthcare system is characterized by extensive reliance on consumer demand and market competition (Hsaio 1992: 617). In private insurance systems, as opposed to state- led NHS systems and social insurance schemes, the purchase of insurance is not mandatory, nor are the insurance companies obliged to accept all applicants for insurance contracts (obligatory underwriting). Insurance companies sell a va riety of contracts that are contingent upon health status, thereby also reflecting consumer’s willingness and ability to pay. If this is viewed as socially unacceptable, direct income transfers to households (e.g. in the form of tax-subsidies) are consistent with the free market model as they do not affect consumers’ preferences and leave the basic incentive structure of the healthcare market untouched (Evans 1983: 65). Nevertheless, and in deep contrast to out-pocket-payment financing, private insurance premiums imply at least some degree of collective or solidarity financ12

Profitization of public hospitals is also very unpopular. In this case a good method for “blame avoidance” (Weaver 1986: 371) is a less visible strategy like functional profitization (Pierson 1996: 177).

21

ing as there is a (ex post) redistribution from those members who stayed healthy, to the ind ividuals who suffered losses (Wille 2002: 10). In provider markets too, market competition is the dominant form of interaction. Service delivery is mainly performed by private providers. In the outpatient sector, physicians gene rally are self- employed and therefore mainly for-profit providers. This also means that healthcare is an industry, where private entrepreneurs are responding to the high mobility of capital (Tuohy 1999: 14; White 2007). Providers are paid on a fee-for-service basis, so that their prices can adapt to the changing market place, while patients have free access to service providers in order to make conscious choices, reflecting upon prices and quality. Ideally, competition tends to render suppliers unable to generate monopoly rents and drive inefficient providers out of the market (Evans 1983). If any regulation is compatible with the market ideology, beneath the granting of property rights by the constitution, this is antitrust legislation to restore competitive market forces when collusion is suspected (Nichols et al. 2004). In our sample of 23 OECD countries, Switzerland (until 1996) and especially the US come very close to an ideal competitive market model, at least in the beginning of our observation period. Greece, although showing a high percentage of private financing, is not typical for a private insurance system. Although private payments prevail in the Greek funding system, most of them come from out-of-pocket. The system logic, therefore, rather is that of a rudimentary social insurance system (BMGS 2003). While private healthcare systems in general score relatively high with regards to responsiveness and choice, their ability to achieve social objectives is limited (Nichols et al. 2004: 20). The major reason for system deficiencies in private insurance systems therefore lies in what is commonly labelled ‘market failure.’ While perfect information is a prerequisite for the functioning of the markets for medical care, de facto information asymmetries exist, causing severe problems of adverse selection and moral hazard 13 (Cutler and Zeckhauser 2000: 566f.). The extensive consumption of medical care due to moral hazard beha viour is not a problem which is unique to private markets; it occurs in all other health insurance systems as well. Yet the private market bears only few mechanisms to prevent moral hazard, as some hierarchical

13

Moral Hazard Adverse selection occurs when an insurer is not able to rate the health risk of the applicants. The average health insurance premium, the insurer will calculate, bases on an average risk expectation. This average premium will attract relatively poor risks and deter the good health risks. Yet if poor risks join the pool the insurer will be forced to increase the premium and good risks will be further deterred. This process can repeat itself with the consequence of a break-down of the insurance market. Moral hazard appears on the demand side and on the supply side of the market as well. As the insured are members of a collective risk pool, they face an incentive to ‚free-riding’, i.e. to consume more care that medically necessary. By the same token, providers may provide more care due to supplier-induced demand, when insurance is involved.

22

intervention is necessary in the regulation of providers’ and patients’ behaviour in order to avoid that phenomenon. Private health insurance systems, therefore, tend to increase healthcare supply and demand as well (Colombo and Tapay 2004: 22). In fact, the US and Switze rland have the most expensive healthcare systems in our sample, consuming about 15 percent of the GDP in 2005 and 11.5 percent, respectively (OECD 2007). In addition, a great deal of these expenditures are ‘waste’ in the sense that they are not employed in the production of health, but rather spent for administrative cost or consumed by price- inflating investment strategies (White 2007; Woolhandler and Himmelstein 2002). The adverse selection problem points to at another deficiency, inherent to a private insurance system. Unregulated private insurance markets are unable to cope with adverse selection, as the first-best market-equilibrium, where all applicants can receive full insurance coverage, is unachievable (i.e. real market failure) (Rothschild and Stiglitz 1976). In a free market, insurers generally respond to adverse selection by the risk-rating of premiums. Yet this method renders premium payments unaffordable especially for those population groups who most urgently need insurance for medical care, i.e. sick and the poor individuals (Cacace et al. 2008: 21f.). Furthermore, as it is impossible to adjust premiums exactly to the corresponding health risks, insurers intend to reduce uncertainty by excluding pre-existing conditions 14 from the benefit package or by completely denying coverage for an applicant (Glied 2001: 964). Therefore the attraction of good risks (cream-skimming) is a dominant competitive strategy of private insurers. The result is an increase in the number of uninsured persons, as experienced drastically in the US healthcare system. Even if we might consider a certain quantity of uninsured as ethically acceptable, the fact that this group does not receive adequate care, translates in higher cost at the societal level (Miller et al. 2004). The growth of hierarchy in private healthcare systems As a consequence of efficiency pressure, therefore, hierarchical elements of regulation in private insurance systems have increased over time. Switzerland, for example, even moved away from a private to a social insurance scheme by establishing mandatory insurance for all citizen (Moser 2005: 15). The system change was enabled by state interference in 1996 through the introduction of the New Law of Health Insurance (Krankenversicherungsgesetz, KVG). With the KVG comprehensive reform plans were encountered with the main objectives to strengthen solidarity thereby also allowing every individual access to high quality 14

Pre -existing conditions are physical or mental conditions already existing before an insurer agrees to insure an individual.

23

health services, and to contain costs (Gerlinger 2003: 7). Also in the US, the public elements grew considerably. From the government side, the programs of Medicare and Medicaid were enacted in 1965, at a time when many elderly persons faced challenges finding affordable coverage within private markets (Colombo and Tapay 2004: 15; Marmor and McKissick 2000). Over time, the inclusion of further groups of the population into the public scheme has continued. Currently, 27 per cent of the American population are covered by Medicare and Medicaid. Interestingly, although coverage increased which means that more individuals and groups were included, the benefit package was quite static over time. Especially Medicare did not respond to changing healthcare needs of the population. Private insurers, by contrast, gradually have included further benefits in their packages quite early in the 1970s thereby proving much more flexibility in the adaptation to the changing needs of the population and therefore greater responsiveness {Oberlander, 2003 #2685: 40; Rothgang, forthcoming #3086}. In the private healthcare systems of the US and Switzerland, therefore, the adverse selection problem was (at least partially) solved through state regulation, either in the form of imposing a system change, or by establishing mandatory insurance for the most expensive health risks. The considerable increase in public funding, from slightly more than 20 percent in 1965 to about 45 percent in 2005 in the US, entailed a substantial rise in hierarchical state regulation, as the pub lic programs came under cost pressure almost from their beginning on (Marmor 2000: 107; Patel and Rushefsky 1999). Especially provider regulation increased, starting with the introduction of Diagnosis Related Groups in 1983. Yet in the realm of private insurance, government regulation was weak, especially vis-à-vis service providers. The medical profession therefore was largely able to preserve their autonomy in their transactions with private insurers (Stone 2000). From the mid 1980s on, vertically integrated managed care organizations gained a foothold. While managed care competed with the traditional indemnity insurers for insured persons, the arrangements per se were not competitively structured. Due to their hierarchical structure, private mana ged care arrangements were able to impose instruments to steer patients and providers through interference in clinical decision making, utilization reviews, and new remuneration methods. Thus, in coping with the efficiency pressure put on the American healthcare system, private managed care arrangements worked as a functional equivalent to government regulation. Health Maintenance Organizations (HMOs) achieved considerable savings, especially in the first decade of their spread. As a consequence of the backlash against HMOs, ‘virtually’ integrated provider networks and bargaining elements prevail today 24

thereby giving some leeway also for negotiation strength and market power in the interaction between insurers and service providers {Rothgang, forthcoming #3086; Hsiao, 2002 #2523}. Managed care was introduced in Switzerland too, yet in this case, as a consequence of state legislation (KVG 1996) and therefore not initiated by private actors. Thus, in sum, in coping with system deficiencies, the US is a textbook example of the growth of hierarchical elements in a private healthcare system, emanating from the side of public and private actors as well. But also the competitively structured insurance system in Switzerland adopted the managed care instrument in order to bring more hierarchy into the delivery system when confronted with the efficiency requirements in the 1990s. On the side of service providers, according to the system logic of private, market based healthcare systems we would expect that most service providers are private for-profit providers. Furthermore, as fiscal deficits increase, we guess that private providers will play a greater role over time. In the US as well as in Switzerland, public service provision is restricted to the inpatient sector, while outpatient providers are exclusively private, most of them indeed forprofit providers15 . In inpatient care, we find mainly non-profit providers (public or private) in both countries (Filippini and Farsi 2004; National Center for Health Statistics 2007). While in the US the majority of inpatient beds is and remains private non-profit, we have no further information on the ownership status for Switzerland, i.e. we are unable to state whether these providers are public or private non-profit. When taking the developments from the 1970s into account, in the US, in light of increasing market competition following the growth of managed care, the government sold its municipal hospitals (Getzen 2004). This material privatization in the US hospital sector accrued to almost equal parts to for-profit and non-profit providers. For-profit providers increased their share from 7 to 13 per cent between 1975 and 2005, while non-profit ownership increased from 63 to about 67 per cent within that time span (Cacace 2007; National Center for Health Statistics 2007). Of course, the growth rate of for-profit hospitals was much more impressive than the increase of non-profit inpatient care provision as it started at a much lower level and their share almost doubled in that time span. Therefore, in the 1980s, there was an increasing concern that a few very large commercial suppliers would come to dominate the hospital industry. Yet, interestingly, this expectation did not come true (Döhler 1990). In contrast, non-profit hospitals continue to play an equally important role in the US; a result which at first sight is 15

In the US, about 40 percent of outpatient physicians were employed, for example by an HMO or in physicianowned practices (AMA 2006). As HMOs can be for-profit (ca. 70 percent) and non-profit (ca. 30 percent), an estimated 12 percent of outpatient physicians are non-profit providers.

25

somewhat at odds with the expectations related to the market-based healthcare type. An explanation for this phenomenon is that the persistent importance of the non-profit sector is a genuine part of the private healthcare system of the US. Non-profit hospitals play a major role as safety-net providers in a healthcare system, where almost 16 percent of the population lack health insurance. For their services, they receive tax subsidies and therefore have to provide community benefits, i.e. free or low cost healthcare services to the poor or ind igent (Gray 1991). Thus non-profit providers remain dominant not only in spite of the private system, but because of it. Since the relative importance of non-profit organizations in providing charity care is declining, ho wever, the current debate is about whether non-profits still deserve their tax-free status today. 16 In sum, therefore, material privatization did not necessarily lead to a profitization of the hospital sector, because non-profit hospitals are still on an expansion path. Nevertheless, efficiency pressure forced hospitals throughout the whole ownership spectrum, to functional privatization. For example, hospitals commission the US service industry with laundry services and catering, ‘meals on wheels’ etc. Also the management functions, like e.g. human resources management and payroll accounting, are transferred to specialized organizations. Most of these highly specialized suppliers of services are private for-profit businesses, therefore functional privatization, in contrast to material privatization, clearly promotes profitization.

4.

Conclusion and Prospects for Further Research

In this paper, we have shown that convergence and the common trends we observed in the healthcare systems of OECD countries can be explained by the reaction of distinct system types to problem pressure. In our examination of the changes for state-led NHS systems, social insurance countries, and private healthcare systems, we demonstrate that it is this dive rsity, which finally ends in convergence amongst systems. The ‘modified problem pressure hypothesis’ we put forward, therefore, emphasizes that problem pressure is mediated by the component factors of the systems themselves. As systems take up new directions of change by integrating features that are non-system specific, they blur in their composite features and ultimately converge. Only with respect to the role of the state as a service provider, a common privatization trend is found as an immediate answer to global efficiency pressure.

16

For a recent discussion of this subject see e.g. the contributions in Health Affairs, web exclusive No. 25 (2006) at www.healthaffairs.org.

26

In the present work, we have laid out the theoretical groundwork for the explanation of healthcare system change. Next steps for research entail an expansion of the empirical basis to include a broader analysis of driving forces, as well as a larger number of cases to insure the validity and generalizability of our findings here. Furthermore, we plan to test parts of the general explanatory model by a quantitative approach. In the first instance, this will be feasible in the qua ntitative dimensions, i.e. in the financing and the service provision dimension.

5.

References

Abel-Smith, Brian and Elias Mossialos (1994) 'Cost Containment and Health Care Reform: A Study of the European Union', Health Policy 28(2), 89-132. Alber, Jens (1989) 'Die Steuerung des Gesundheitssystems in vergleichender Perspektive', Journal für Sozialforschung 29(3), 259-84. Alber, Jens (1992) Das Gesundheitswesen der Bundesrepublik Deutschland. Entwicklung, Struktur und Funk tionsweise, Frankfurt a. M.: Campus. American Medical Association (2006) 'Physician Statistics' (Online: http://www.amaassn.org/ama/pub/category/2676.html, last access: 16 October 2006). Anell, Anders (2005) 'Swedish Health Care under Pressure', Health Economics 14(S1), 237-54. BMGS (2003) Sozial-Kompass für Europa – Soziale Sicherheit in Europa im Vergleich, Bonn: Bundesministerium für Gesundheit und Soziale Sicherung,. Böckmann, Roman (2007) 'Von der Selbstverwaltung zum regulierten Gesundheitsmarkt', Diskussionspapier des Instituts für Politikwissenschaft und der GraSP Münster No. 1, Münster: GraSP. Boscheck, Ralf (2005) 'Healthcare Reforms and Governance Concerns. The Cases of the United States, the United Kingdom and Germany', Intereconomics 40(2), 75-88. Busse, Reinhard and Annette Riesberg (2004) Health Care Systems in Transition: Germany, Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies. Busse, Reinhard, Tom van der Grinten and Per-Gunnar Svensson (2002) 'Regulating Entrepreneurial Behavior in Hospitals: Theory and Practice', in Richard B. Saltman, Reinhard Busse and Elias Mossialos (eds.) Regulating Entrepreneurial Behavior in European Health Care Systems, Buckingham: Open University Press, 126-45. Cacace, Mirella (2007) 'The Changing Public/Private-Mix in the American Health Care System', TranState Working Paper No. 58, Bremen: TranState Research Center. Cacace, Mirella (forthcoming) 'The Coexistence of Market and Hierarchy in the US Healthcare System', in Heinz Rothgang, Mirella Cacace, Simone Grimmeisen, Uwe Helmert and Claus Wendt (eds.) The Changing Role of the State in OECD Health Care Systems. From Heterogeneity to Homogeneity?, Basingstoke: Palgrave Macmillan, forthcoming. Cacace, Mirella, Heinz Rothgang and Theresa Thompson (2008) 'Harnessing Competition, Protecting Solidarity: A Comparison of Healthcare Markets in Germany, Great Britain, and the United States', TranState Working Paper No. forthcoming, Bremen: TranState Research Center. Carrin, Guy and Chris James (2004) Reaching Universal Coverage via Social Health Insurance: Key Design Features in the Transitional Period, Geneva: World Health Organization; http://www.karmayog.org/redirect/strred.asp?docId=2562) Colombo, Fancesca and Nicole Tapay (2004) Private Health Insurance in OECD Countries: The Benefits and Costs for Individuals and Health Systems, Paris: OECD. Commissie Dekker (1987) Bereidheid tot verandering [Willingness to Change] , The Hague: DOP. Cutler, David M. and Richard J. Zeckhauser (2000) 'The Anatomy of Health Insurance', in Anthony J. Culyer and Joseph P. Newhouse (eds.) Handbook of Health Economics, Amsterdam: Elsevier, 563-637. den Exter, André, Herbert Hermans, Milena Dosljak and Reinhard Busse (2004) Health Care Systems in Transition: Netherlands, Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies. Döhler, Marian (1990) Gesundheitspolitik nach der ‚Wende'. Policy-Netzwerke und ordnungspolitischer Strategiewechsel in Großbritannien, den USA und der Bundesrepublik Deutschland, Berlin: edition sigma. Döhler, Marian and Philip Manow-Borgwardt (1992) 'Gesundheitspolitische Steuerung zwischen Hierarchie und Verhandlung', MPIfG Discussion Paper No. 9, Köln: Max-Planck-Institut für Gesellschaftsforschung. Donaldson, Cam, Karen Gerard and Craig Mitton (2005) 'Efficient Purchasing in Public and Private Healthcare Systems: Mission Impossible?' in Alan Maynard (ed.) The Public-Private Mix for Health, Oxford: Radcliffe, 21-41.

27

Eeckloo, Kristof, Luc Delesie and Arthur Vleugels (2007) 'Where Is the Pilot? The Changing Shapes of Governance in the European Hospital Sector', The Journal of the Royal Society for the Promotion of Health 127(2), 78-86. Ess, Silvia M., Sebastian Schneeweiss and Thomas D. Szucs (2003) 'European Healthcare Policies for Controlling Drug Expenditure', Pharmaeconomics 21(2), 89-103. Evans, Robert G. (1983) 'Incomplete Vertical Integration in the Health Care Industry: Pseudomarkets and Pseudopolicies', The Annals of the American Academy of Polical and Social Science 468, 60-87. Fattore, Giovanni (1999) 'Cost Containment and Health Care Reforms in the British NHS', in Elias Mossialos and Julian Le Grand (eds.) Health Care and Cost Containment in the EU, Aldershot: Ashgate, 733-81. Ferrera, Maurizio, Anton Hemerijck and Martin Rhodes (2001) 'The Future of the 'European Social Model' in the Global Economy', Journal of Comparative Policy Analysis 3(2), 163-90. Field, Mark G. (1999) 'Comparative Health Systems and the Convergence Hypothesis. The Dialectics of Universalism and Particularism', in Francis D. Powell and Albert F. Wessen (eds.) Health Care Systems in Transition. An International Perspective, Thousand Oaks: SAGE Publications, 35-44. Figueras, Josep, James C. Robinson and Elke Jakubowski (eds.) (2002) Purchasing to Improve Health Systems Performance, Maidenhead: Open University Press. Filippini, Massimo and Mehdi Farsi (2004) An Analysis of Efficiency and Productivity in Swiss Hospitals , Zurich: Swiss Federal Statistical Office and the Swiss Federal Office for Social Security; France, George, Francesco Taroni and Andrea Donatini (2005) 'The Italian Health-care System', Health Economics 14(S1), 187-202. Frisina, Lorraine and Klaus Albrecht (forthcoming) 'The Nature of Policy Values in the Healthcare Systems of Great Britain, Germany and the United States', in Heinz Rothgang, Mirella Cacace, Simone Grimmeisen, Uwe Helmert and Claus Wendt (eds.) The Changing Role of the State in OECD Health Care Systems. From Heterogeneity to Homogeneity?, Basingstoke: Palgrave Macmillan, forthcoming. Gerlinger, Thomas (2003) 'Das Schweizer Modell der Krankenversicherung. Zu den Auswirkungen der Reform von 1996', Papers in Public Health No. SP I 2003-301, Berlin: Wissenschaftszentrum Berlin für Sozia lforschung. Getzen, Thomas E. (2004) Health Economics. Fundamentals and Flow of Funds, New York, NY: Wiley. Giaimo, Susan (2002) Markets and Medicine. The Politics of Health Care Reform in Britain, Germany, and the United States, Ann Arbor: University of Michigan Press. Giaimo, Susan and Philip Manow (1999) 'Adapting the Welfare State: The Case of Health Care Reform in Britain, Germany, and the United States', Comparative Political Studies 32(8), 967-1000. Gilardi, Fabrizio, Katharina Füglister and Stéphane Luyet (2005) 'Interdependent Welfare States: The Diffusion of Health Care Reforms in OECD Countries', Paper Presented at the 'Anual Conference of the Network for European Social Policy Analysis', University of Fribourg, 22-24 September 2005. Glied, Sherry (2001) 'Health Insurance and Market Failure since Arrow', Journal of Health Politics, Policy and Law 26(5), 957-65. Gray, Bradford H. (1991) The Profit Motive and Patient Care: The Changing Accountability of Doctors and Hospitals, Cambridge, MA: Harvard University Press. Greß, Stefan, Peter P. Groenewegen, Jan Kerssens, Bernard Braun and Jürgen Wasem (2002) 'Free Choice of Sickness Funds in Regulated Competition: Evidence from Germany and The Netherlands', Health Policy 60, 235-54. Greß, Stefan, Maral Manouguian and Jürgen Wasem (2006) 'Krankenversicherungsreform in den Niederlanden. Vorbild für einen Kompromiss zwischen Bürgerversicherung und Pauschalprämie in Deutschland?' Diskussionsbeiträge aus dem Fachbereich Wirtschaftswissenschaften, Universität Duisburg -Essen No. 150, Essen. Greß, Stefan, Maral Manouguian and Jürgen Wasem (2007) Health Insurance Reform in the Netherlands, in: CESifo DICE Report, 63-7 Grimmeisen, Simone (forthcoming) 'The Role of the State in the British Healthcare System - between Marketization and Statism', in Heinz Rothgang, Mirella Cacace, Simone Grimmeisen, Uwe Helmert and Claus Wendt (eds.) The Changing Role of the State in OECD Healthcare Systems. From Heterogeneity to Homogeneity?, Basingstoke: Palgrave Macmillan, forthcoming. Hacker, Jackob S. (2002) The Divided Welfare State: The Battle over Public and Private Social Benefits in the United States, Cambridge: Cambridge University Press. Hacker, Jacob S. (2004) 'Review Article: Dismantling the Health Care State? Political Institutions, Public Policies and the Comparative Politics of Health Care Reform', British Journal of Political Science 34, 693724. Hall, Jane and Elizabeth Savage (2005) 'The Role of the Private Sector in the Australian Healthcare System', in Alan Maynard (ed.) The Public-Private Mix for Health, Oxford: Radcliffe, 247-78. Henke, Klaus-Dirk and Lutz Reimers (2006) 'Zum Einfluss von Demographie und medizinisch-technischem Fortschritt auf die Gesundheitsausgaben', ZIGprint No. 8, Berlin: Zentrum für innovative Gesundheitstechnologie.

28

Hirschman, Albert O. (1970) Exit, Voice, and Loyalty. Responses to Decline in Firms, Organizations and States, Cambridge: Harvard University Press. Houtman, Dick and Stef Aupers (2007) 'The Spiritual Turn and the Decline of Tradition: The Spread of PostChristian Spirituality in 14 Western Countries, 1981-2000', Journal for the Scientific Study of Religion 46(3), 305-20. Hsaio, William C. (1992) 'Comparing Health Care Systems: What Nations Can Learn from One Another', Journal of Health Politics, Policy and Law 17(4), 613-36. Hsiao, William C. (2002) 'Erfahrungen mit staatlicher und privater Regulierung im US-amerikanischen Gesundheitssystem', Managed Care 8, 13-5. Jacobs, Rowena and Maria Goddard (2000) Social Health Insurance Systems in European Countries. The Role of the Insurer in the Health Care System: A Comparative Study of Four European Countries, York: Centre for Health Economics; http://www.york.ac.uk/inst/che/pdf/op39.pdf) Kanavos, Panos and J. Yfantopoulus (1999) 'Cost Containment and Health Expenditure in the EU: A Macroeconomic Perspective', in E Mossialos and Julian Le Grand (eds.) Health care and cost containment in the European Union, Aldershot: Ashgate, 155-96. Klein, Rudolf (1996) 'Self-Inventing Institutions: Institutional Design and the U.K. Welfare State', in Robert E. Goodin (ed.) The Theory of Institutional Design, Cambridge: Cambridge University Press, 240-55. Klein, Rudolf (2005) 'The Public -Private Mix in the UK', in Alan Maynard (ed.) The Public-Private Mix for Health, Oxford: Radcliffe, 43-62. Lewis, Richard, Arturo Alvarez Rosete and Nicholas Mays (eds.) (2006) How to Regulate Health Care in England? An International Perspective, London: King's Fund. Maarse, Hans (2004) 'Towards a Comparative Analysis of Privatisation in European Health Care', in Hans Maarse (ed.) Privatisation in European Health Care. A Comparative Analysis in Eight Countries, Maarssen: Elsevier gezondheidszorg, 169-98. Maarse, Hans and Yvette Bartholomée (2007) 'A Public-Private Analysis of the New Dutch Health Insurance', European Journal of Health Economics 8(1), 77-82. Marchildon, Gregory P. (2006) Health Care Systems in Transition: Canada, Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies. Marmor, Theodore (2000) The Politics of Medicare, 2 nd Ed., New York: De Gruyter. Marmor, Theodore R. and Gary J. McKissick (2000) 'Medicare’s Future: Fact, Fiction and Folly', American Journal of Law and Medicine 26(2-3), 225-. Mason, Anne and Peter Smith (2006) 'Regulation and Relations between the Different Participants in the English Health Care System', in Francoise Leclerc (ed.) Reforms and Regulation of Health Care Systems in Europe, Paris: DREES, 253-70. Mechanic, David and David A. Rochefort (1996) 'Comparative Medical Systems', Annual Review of Sociology 22, 239-70. Miller, Wilhemine, Elizabeth Richardson Vigdor and Willard G. Manning (2004) 'Covering the Uninsured. What Is It Worth?' Health Affairs - Web Exclusive, w4-157-67. Moe, Terry M. (1990) 'Political Institutions: The Neglected Side of the Story', Journal of Law, Economics, and Organization 6(Special Issue), 213-53. Moser, Julia (2005) 'Expanding the Welfare State after the Golden Age: The Case of Switzerland', TranState Working Papers No. 28, Bremen. Mrazek, Monique (2002) 'Comparative Approaches to Pharmaceutical Price Regulation in the European Union', Croation Medical Journal 43(4), 453-61. National Center for Health Statistics (2007) Health, United States 2007. With Chartbook on Trends in the Health of Americans, Hyattsville: U.S. Department of Health and Human Services; Nichols, Len M., Paul B. Ginsburg, Robert A. Berenson, Jon Christianson and Robert E. Hurley (2004) 'Are Market Forces Strong Enough to Deliver Efficient Health Care Systems? Confidence is Waning', Health Affairs 23(2), 8-21. Nixon, John (2002) Convergence: An Analysis of European Union Health Care Systems 1960-95, Submission for the degree of PhD, September 2002, Department of Economics and Related Studies: York Oberlander, Jonathan (2003) The Political Life of Medicare, Chicago: University of Chicago Press. OECD (2004) Proposals for a Taxonomy of Health Insurance, Paris: OECD. OECD (2007) OECD Health Data. October Update, Paris: OECD. Olson, Mancur (1965) The Logic of Collective Action: Public Goods and the Theory of Groups, Cambridge: Harvard University Press. Olson, Mancur (1982) The Rise and Decline of Nations. Economic Growth, Stagflation and Social Rigidities, New Haven: Yale University Press. Osborne, David and Ted Gaebler (1992) Reinventing Government. How the Entrepreneurial Spirit is Transforming the Public Sector, Reading, MA: Addison-Wesley. Patel, Kant and Mark E. Rushefsky (1999) Health Care Politics and Policy in America, Armonk, NY: M. E. Sharpe.

29

Pedersen, Kjelld Møller (2005) T ' he Public-private Mix in Scandinavia', in Alan Maynard (ed.) The PublicPrivate Mix for Health, Oxford: Radcliffe Publishing, 161-90. Pierson, Paul (1996) 'The New Politics of the Welfare State', World Politics 48(January), 143-79. Rice, Thomas (1998) The Economics of Health Reconsidered, Chicago: Health Administration Press. Rothgang, Heinz (2006) 'Die Regulierung von Gesundheitssystemen in vergleichender Perspektive: Auf dem Weg zur Konvergenz?' in Claus Wendt and Christof Wolf (eds.) Soziologie der Gesundheit. Sonderheft 46/2006 der Kölner Zeitschrift für Soziologie und Sozialpsychologie, Opladen/ Wiesbaden: Verlag für Sozialwissenschaften, 298-319. Rothgang, Heinz, Mirella Cacace, Simone Grimmeisen, Uwe Helmert and Claus Wendt (forthcoming) The Changing Role of the State in OECD Health Care Systems. From Heterogeneity to Homogeneity?, Basingstoke: Palgrave Macmillan, forthcoming. Rothgang, Heinz, Mirella Cacace, Simone Grimmeisen and Claus Wendt (2005) 'The Changing Role of the State in Health Care Systems', in Stephan Leibfried and Michael Zürn (eds.) Transformations of the State?, Cambridge: Cambridge University Press, 187-212. Rothgang, Heinz, Herbert Obinger and Stephan Leibfried (2006) 'The State and its Welfare State: How do Welfare State Changes affect the Make-up of the Nation State?' Social Policy & Administration 40(5 (in Überarbeitung)). Rothschild, Michael and Joseph Stiglitz (1976) 'Equilibrium in Competitive Insurance Markets: An Essay on the Economics of Imperfect Information', The Quarterly Journal of Economics 90(4), 629-49. Sappington, David E.M. (1991) 'Incentives in Principal-agent Relationships', The Journal of Economic Perspectives 5(2), 45-66. Scharpf, Fritz W. (1989) 'Decision Rules, Decision Styles, and Policy Choices', Journal of Theoretical Politics 1(2), 149-76. Scharpf, Fritz W. (1993) 'Coordination and Hierarchies in Networks', in Fritz W. Scharpf (ed.) Games in Hierarchies and Networks: Analytical and Empirical Approaches to the Study of Governance Institutions, Frankfurt a.M.: Campus. Schmid, Achim, Claus Wendt and Uwe Helmert (forthcoming) 'The Changing Role of the State in Healthcare Service Provision', in Heinz Rothgang, Mirella Cacace, Simone Grimmeisen, Uwe Helmert and Claus Wendt (eds.) The Changing Role of the State in OECD Health Care Systems. From Heterogeneity to Homogeneity?, Basingstoke: Palgrave Macmillan, forthcoming. Schneider, Volker and Marc Tenbücken (2004) Der Staat auf dem Rückzug. Die Privatisierung öffentlicher Infrastrukturen, Frankfurt: Campus. Schut, Frederik T. (1995) 'Health Care Reform in the Netherlands: Balancing, Corporatism, Etatism and Market Mechanisms', Journal of Health Politics, Policy and Law 20(3), 615-52. Scott, Claudia (2001) Public and Private Roles in Health Care Systems - Reform Experience in Seven OECD Countries, Buckingham: Open University Press. Stone, Deborah (2000) 'United States', Journal of Health Politics, Policy and Law 25(5), 953-8. Thelen, Kathleen (2003) 'How Institutions Evolve: Insights from Comparative-historical Analysis', in James Mahoney and Dietrich Rueschemeier (eds.) Comparative Historical Analysis in the Social Sciences, New York: Cambridge University Press, 208-40. Tuohy, Carolyn H., Colleen M. Flood and Marc Stabile (2004) 'How Does Private Finance Affect Public Health Care Systems? Marshalling the Evidence from OECD Nations', Journal of Health Politics, Policy and Law 29(3), 359-96. Tuohy, Carolyn Hughes (1999) Accidental Logics, New York: Oxford University Press. Visser, Jelle (2006) 'Union Membership Statistics in 24 Countries', Monthly Labor Review 129(1), 38-49. Visser, Jelle and Anton Hemerijck (1997) A Dutch Miracle. Job Growth, Welfare Reform and Corporatism in the Netherlands, Amsterdam: Amsterdam University Press. Weaver, Kent (1986) 'The Politics of Blame Avoidance', Journal of Public Policy 6(4), 371-98. White, Joseph (2007) 'Markets and Medical Care: The United States, 1993-2005', The Milbank Quarterly 85(3), 395-448. Wille, Eberhard (2002) 'Reformoptionen der Beitragsgestaltung in der gesetzlichen Krankenversicherung', Gesundheit und Gesellschaft 2(3), 7-14. Wilsford, David (1995) 'States Facing Interests: Struggles over Health Care Policy in Advanced, Industrial Democracies', Journal of Health Politics, Policy and Law 20(3), 571-613. Woolhandler, Steffie and David U. Himmelstein (2002) 'Paying for National Health Insurance - and not Getting It.' Health Affairs 21(4), 88-98. Wörz, Markus (2007) Macht die Krankenhausträgerschaft einen Unterschied? Eine vergleichende Untersuchung von Trägerunterschieden im akutstationären Sektor in Deutschland und den Vereinigten Staaten von Amerika, Dissertation, Institut für Technologie und Management, TU Berlin: Berlin

30