This document summarizes a lecture on theories of the welfare state and healthcare systems. It discusses key variables like types of welfare states, political systems, and interest groups. It also examines different theoretical approaches for understanding policy change, including social context theories, actor-centered theories, and institutional theories. The lecture compares concepts like preferences, power, and resources within different theoretical frameworks and maps out causal factors like social structures, politics, and institutions that can influence policy outcomes.

1. 2005
Health Politics:
Lecture 10
Summary
Ana Rico, Associate Professor
Department of Health Management and Health Economics
ana.rico@medisin.uio.no

2. 2005
THE DEPENDENT VARIABLES:
Types of WS and HC systems
- Policy instruments
- Impact: Social outcomes

3. 2005
DEMOCRATIC
GOVERNMENT &
INSTITUTIONS
PUBLIC & SOCIAL
INSURANCE
PUBLIC WELFARE
SERVICE
PRODUCTION
GOVERNANCE & POLITICS
THE MARKET
Financial markets
Product markets
INTEREST
GROUPS
PRIVATE FINANCERS:
Banks, insurers, citizens
PRIVATE PROVIDERS: Hospitals,
doctors, schools, nursing homes
THE
WS
1. THE WS, POLITICS & MARKETS: Definition

4. 2005
EGALITARIAN Outcomes REGRESSIVE
-
%
Covered
+
2 & 3. TYPES OF WS : Instruments and consequences
Pure (unmixted)
Socialdemocratic
UNIVERSAL
RESIDUAL
Pure liberal:
Public insurance
for the poor
Pure Christian
Democratic:
Employees
Pure ChisDem:
Non-employed
Pure CD:
Private insurance
for employers
Pure
liberal:
Private
insurance
for
the
non-poor
Based on Esping-Andersen, 1990

5. 2005
Source: McKee, 2003

6. 2005
CHANGES IN WELFARE POLICY
 WS expansion
Expansion of coverage, benefits and expenditure
 WS retrenchment
Decrease in coverage, benefits and expenditure
 WS resilience
Stable in coverage, benefits and expenditure. Resistant to change
 WS re-structuring
Change in distribution of benefits & expenditure across social
groups

7. 2005
HC in CRISIS: Canada & US

8. 2005
HC IN CRISIS? Canada, gov. approval

9. 2005
THE INDEPENDENT VARIABLES:
- The political sysem
- Context, actors, instits. , action

10. 2005
a. Demands and supports
b. Access to the political system
c. Decision-making
d. Institutional change
e. Impact of policy
f. Distribution of costs and benefits
Policy actors:
•STATE-, POL. PARTs (IGs)
Policy
change
INPUTS
Outcomes
THE POLITICAL SYSTEM
POLICY (SUB-) SYSTEM
a c
d e
b
OUTPUTS
Outputs
POLICY
POLITICS
POLITY
f
HC
SYSTE
M
Political, policy/sociopolitical and social systems
SOCIAL CONTEXT
Institutions:
• Const. (interorg.)
• Organiz. Struct.
Interactions:
• Coalitions/competit.
• Leadership/strategy
Sociopol. actors:
• IGs, Prof Ass., Unions
• Citizens, Mass media
• Political parties
CONSTITUTION
CULTURE
* Org.Struct.
* Subcultures
/pol.identities
* Ideologies
* Ideas
Social organiz.
• Associations
• Churches
• Firms
Social groups
- Communities
- Ethnia, gender
- Social classes

11. 2005
$
The social context
The political game
The socio-political context
Policy
MACRO: Political
actors
MESO:
Sociopol. actors
MICRO:
Social
actors
Citizens’
Associations
Political
parties’
members IGs
- Bussiness
- Insurance
Profes. +
providers’
Assoc.
Patients’
Assoc. Patients’
Advisors and
managers

12. 2005
ACTION-CENTERED THEORIES. 1.1. RQs
Social context
Policy context
State context
RQ 1. Who participates? (=
seeks to influence policy)
RQ 2. Who
influences
policy?
REPRESENTATIVE DEMOCRACY “DIRECT” DEMOCRACY
RQ 3. Who
governs?
RQ 4.
How it
governs?

13. 2005
THE THEORIES:
- Concepts
- Hypotheses
- Causal maps

14. 2005
 SOCIAL CONTEXT: The state as a ‘transmission belt’ of social pressures
 STATE-CENTRIC: The state as a unitary, independent actor with formal
monopoly of (residual) power over policy-making
 STATE-SOCIETY: The state as a set of political representatives and policy
experts with preferences and action partly independent, and partly
determined by a wide range of social actors’ pressures
 INSTITUTIONALIST: The state as a set of political institutions; or as a set of
elites with preferences and actions mainly determined by institutions
 ACTION: As a set of political organizations which respond to context,
sociopolitical actors and institutions; and which compete and cooperate
(=interact) to make policy

CONCEPTS (4): The state

15. 2005
SOCIAL PRESSURES OLD INSTITUTIONALISM
Formal political institutions
SOCIALACTORS
(IGs: dependent on
social pressures)
POLITICALACTORS
(STATE: independent
of social pressures)
SOCIOP. ACTORS
(STATE-SOCIETY:
interdependent)
NEW INSTITUTIONALISM
(state institutions &
state/PPs/IGs’ organization)
POWER-CENTRED
THEORIES
(interactions among
collective actors &
social structure)
RATIONAL
CHOICE
(interactions
among
individuals
ACTOR-CENTERED
INSTITUTIONALISM
(interactions among
institutions & elites)
1950s/60s:
SOCIAL
CONTEXT
1970s/1980s:
ACTOR-
CENTRED
1990s:
INSTITUT-
IONALISM
(+state-society)
2000s:
ACTION
THEORIES
SOCIAL & POLITICAL THEORIES
L3
L5
L2, L4
L6
L7
L9
L4, L9
L7
L7, L9

16. 2005
CAUSAL MAPS
Government
action/Policy
change
Source: Orloff & Skocpol, 1984
State formation
(bureaucratization,
democratization
Socioeconomic
& cultural
changes
Changing class
structure &
new social
needs
Proposals of
politically
active groups
How state
organizations &
parties operate
Changing group and
social needs
What politically
active groups
propose
Government
action/Policy
change
Social context & social actors theories
State-centered theories

17. 2005
CAUSES OF THE WS
Based on Esping-Andersen 2000 & 2003; Jenkings & Brents 1987; Skocpol 1987
Policy
change
Social
structure
Christian &
conservative
parties, insurers,
unions & voters
Socialdemocratic
parties, unions &
voters
Coalition formation &
Political competition
* Electoral campaigns
* Policy campaigns
Dominant
national
subcultures
Liberal parties,
progressive (state)
elites, social protest
SOCIAL POLITICAL POLICY
SOCIOPOL.

18. 2005
THE THEORIES (2):
- Old and new debates

19. 2005
SOCIAL vs. POLITICAL THEORIES
 Bussiness associations & Unions
 Professional associations
 Policy experts
 Citizens´ preferences (= PO)
 Mass media
 Social movements
“FATE”
SOCIAL CONTEXT
 Convergence theory
 Structural theories:
capitalist/working class
strength depends on
distribution of ownership
 Cultural theories:
national (anti- or statist)
cultures inherited from
history
 Contextual theories:
unusual conjunctures,
policy windows
CHANCE
CHOICE
INTEREST
GROUPS
(as delegates
of social
groups 
dependent on
mandate)
POLITICALACTORS
(as representatives) 
independent of social groups
SOCIOPOLIT.
ACTORS 
interindependent

20. 2005
PREFERENCES POWER ACTION
ACTOR-CENTRED
THEORIES (state-
centric/state-society)
Public interest
(officials’ autonom.
prefs./socioP infl.)
State/SocioP
capacity: inst + fin
+ know + CA res.
Autonomous/
Dependent on
socioP influen.
INSTITUTIONAL
THEORIES
Institutional norms
& values
Formal institutions Induced –
‘socialized’
RATIONAL CHOICE
Game theory
Private (self-)
Interests
Financial
Resources
Strategic
ACTOR-CENTRED
INSTITUTIONALISM
Ideas, interests &
institutions
Instit. (+ fin &
know) resources
Strategic/
Induced
POWER-CENTRED
THEORIES
Resources
(ideas), interests
& ideologies
Fin + know +
instit + org. + CA
resources
Strategic/
Dependent
on socioP infl.
ACTORS & ACTION ACROSS THEORIES

21. 2005
 Positions in the main debate on causation in policy sciences:
 From actor-centered (simple) to action-centered (complex):
 From monocausal explanations: emphasys on one actor as key determinant
 To multicausal models which:
 Compare the relative preferences & power resources of actors
 Analize the interactions between institutions, past policy and context
 Map actors’ changing choices and strategies
 Examine actors’ interactions in the political process...
Rational choice Power-centred theories
• Individuals
• Interests
• Resources $
• Competition
• Social groups
• Power resources
• Collective action
• Coalitions
Institutionalism
• Organizations
• Rules & norms
• Expectations
• Formal power
Rational
models
Incremental
models
Interaction
models
ACTION-CENTERED THEORIES

22. 2005
TOWARDS TWO MAIN THEORIES?
POWER-CENTRED TEORIES
 FROM (EC.) ACTION THEORIES:
 Changing strategy & resources as key causes of
policy change
 Actors as complex coalitions of political
organizations and social groups steered by
political leaders & enterpreneurs
 FROM STRUCTURAL THEORIES:
 Social power resources as the main actors’
characteristic
 Politics as an unequal, oligopolistic game in
which stakeholders have permanent advantage
 Access and strength of stakechallengers &
weakest social groups explains policy change
 Stakeholders must be divided
ACTOR-CENTRED INSTITUTIONALISM
 FROM (EC.) ACTION THEORIES:
 Choice & strategy as key causes of policy
change
 Political actors as individuals  links with
society reduced to basic resources ($, vote) +
internal cohession assumed rather than
investigated
 Preferences as the main actors’ feature +
formal institutional power resources
 Politics as a balanced game: interests compete
on equal terms, none has permanent
advantage
 FROM ACTOR-CENTRED THEORIES:
 Dominant actors (with formal, institutional
political power) explain policy change

23. 2005
CAUSES OF POLICY CHANGE:
Operationalization in WS/HC research
Adapted from Walt and Wilson 1994
 Distrib. of formal pol. power:
electoral law, constitution,
federalism, corporatism
 Contracts and org. structures
 Norms of behaviour
 Sanctions/incentives
CONTEXT
INSTITUTIONS
POLITICS:
Strategies,
Interactions
Individual and collective
• Socioeconomic structure:
• Ownership, income
• Education, knowledge
• Social capital (status, support)
• Sociopolitical structure:
• Cleavages and political identities
• Values: Culture and subcultures
-
 Access & participation
 Policy strategies
 Coalition-building
 Competition and cooperat.
 Changing resources
 Learning
POLICY
 Entitlements & rights
 Regulation of power, ownership,
behaviour, contracts)
 Redistribution: Financing & RA
 Production of goods & services
 Conjunctural factors: ec crisis, wars
 Interest groups
 Profesional assocs.
 Poilitical parties
 State authorities
 Citizens: PO/SM
 Mass media
POLITICAL ACTORS
Preferences
Resources
Formal and informal

24. 2005
EVIDENCE:
DETERMINANTS OF
WS EXPANSION

25. 2005
Actor-centred institutionalist theory: HUBER et al 1993 (cont.)
First incorporation of political institutions (‘constitutional structure’)
 Strength of federalism: low, medium, high
 Strength of bicameralism: low, medium, high
 Existence of presidentialism: yes, no
 Electoral system: Majoritarian, proportional modified, proportional
 Popular referendum: yes, no
 Left corporatism: degree
 (Openess of voting regulation: estimated via voter turnout)
 First disaggregation of the DV: The outcome we should study is not pro-WS
or anti-WS but but rather the type of welfare policies: eg.
 Expenditure in Social Security benefits (total)
 Expenditure in transfer payments (cash transfers; excludes health care)
 Government revenue (indicator of state capacity  state ownership)
 Entitlements: who are the beneficiaries, on which basis (income,
employment, citizenship)  Decommodification index (L1)
 Benefits equality (vs. Benefits proportional)  REDISTRIBUTION
EVIDENCE

26. 2005
1. Socioeconomic context (as control variables)
 Aged, unemployed, economic growth, price & profits level
2. Actors (1): Partisanship theory
 Socialdemocratic government boost expenditure, universalism & public
provision of services + weak effects on cash transfers
 Christian Democratic parties boost cash transfers proportional to income
3. Actors (2): Statist theory
 Strong + effects of state fiscal capacity
 Weaker effects of state employment capacity
4. Institutions: Statist/institutionalist theory
 Inconsistent effects of government centralization and corporatism
 Significant effects of constitutional structure (number of veto points)
5. Process and action
 Strong + effects of political mobilization (voting) of the lower classes
 But not of social protest
Actor-centred institutionalist theory: HUBER et al 1993 (cont.)
EVIDENCE

27. 2005
General findings on causal mechanisms behind WS expansion
 A. Some factors have direct, clear effects:
 Strength of Social & Christian Democracy (strong subcultures + parties)
 Constitutional structure (institutional concentration of state power)
 State fiscal capacity (financial power resources of the state)
 B. Other factors have less direct effects, either contingent (on
conjuncture/country) and/or conditional (on interactions with other vars.)
 Eg.: Federalism, social protest, economic context, state employment
capacity
 C.Other factors are so correlated to each other that is difficult to know about
their independent effects on policy
 Eg.: Aging and left vote; consensual democracy and corporatism
Actor-centred institutionalist theory: HUBER et al 1993 (cont.)
EVIDENCE

28. 2005
1. Interactions among IVs  or need to split into two (recodification)
 1. Social protest (* social groups):
 Mobilization of lower classes: + WS
 Mobilization of upper classes: - WS
 Mobilization aparently no signficant effects on WS
 Need to model the interaction= No. Mobilized * Predominant upper (0) /
lower (1) classes
 Or split the varible No. mobilized lower classes/Idem upper
2. Correlations between Ivs (multicollineality): need to ommitt some
 1. Ec. development, old age and left vote:
Direct or indirect effects of aging?
 2. Openess of the economy, left & ChD vote, corporatism, WS expenditure
Aging
Left vote
WS expansion
ACTION-C. THEORIES. 4. Evidence

29. 2005
A. Power-centred theory: Hichs & Mishra (cont.) :
RESOURCES PRO-WELFARE ANTI-WELFARE
Political-CA resources
 Central government
 Interest organization
 Political mobilization
 Voting mobilization
Left & (ChD) center parties
Organized pro-W group activism
Social protest (lower classes)
Newly mobilized voters
Right parties
Organized a-W group activ.
Direct action (upper classes)
Low voter turnout
Institutional resources
 Territ. centralization
 Statutory access of Igs
Unitary countries
YES: Left corporatism
Federal/devolved countries
NO: Pluralism
Financial resources
State fiscal & fin. capacity
State involvmnt as
producer
High profit rates, inflation (?)
High revenue as % of GDP
High public as % tot employment
Low profit rates, deflation
Low revenue as % GDP
Low % public employment
Policy legacy-social
learning–national culture
High status civil service,
collectivism, equity
Corrupted bureaucracies,
individualism, freedom
ACTION-CENTRED THEORIES. 4. Evidence

30. 2005
THE FUTURE:
THE BATTLE FOR PUBLIC OPINION
IN HEALTH POLITICS

31. 2005
WHY IS RELEVANT? (1)
Public opinion = citizens’s preferences and perceptions
1. AS AN INPUT in health care (HC) reform
 Citizens as voters (voice), users (exit) and tax-payers (loyalty) in
democracies
 Main input in politicians’ utility functions
 An independent determinant of policy?
The debate on manipulation: Schumpeter vs. Jacobs
 A critical determinant of policy when...
 Well-established, non-ambivalent attitudes resulting from active
interpretation & discussion (political mobilization and civic
culture)
 Democratic competition: divergent elites & messages
 Very popular or impopular policies (issue salience)
Schumpeter JA (1950): Capitalism, Socialism and Democracy, NY: Harper.
Jacobs (2001): Manipulators and manipulation: Public opinion in a representative
democracy, Journal of Health Politics, Policy and Law, 26, 6, 1361-1373.

32. 2005
In health care:
 critical for electoral success & democratic legitimacy
 intense preferences but high asymmetric information
In health care reform:
 Jacobs 1992: undivided and unambiguous PO reinforces state autonomy
as it counterbalances IG pressures (UK 1945 vs US 1965);
 Navarro 1989/Quadagno 2004: powerful IGs in the USA (AMA 1920s-
1960s; Insurers 1980s-2000s; both) invest substantial resources in
counter-reform PO campaigns (=Immergut 1992 on Switzerland)
 Jacobs 2003: Harry & Louise against the Clintons: unmanipulated PO
requires competitive mass media + political mobilization (soc. mov.)
 Briggs 2000 (/Hall 1993/Weir & Skocpol 1984) : Social scientists, unions
and policy enterpreneurs played a critical role in counterbalancing IGs
campaigns in Europe
WHY IS RELEVANT? (2)

33. 2005
2. As a PROXY of PROCESS
 Access, Pathways, Management
 Information, Trust, Shared decision-making
3. AS AN OUTCOME of HC (reform)
 Equity, financing and distributive justice
 Satisfaction, quality of life and productive efficiency
NOTE:
 Citizens’ disatisfaction, AND perceptions of process &
equity problems are indicators of bad performance of
public HC
 Perceived performance constitutes the most important
cause=input of HC reform for policy-feedback theory
WHY IS RELEVANT? (3)

34. 2005
 Interests: social structure vs. choice
 Values  CULTURE
 As core beliefs: solidarity, equality, safety
 Varying by ideological subcultures:
 Social-democracy: universality, solidarity
 Political liberalim: equality of opportunity
 Progressive conservatism: responsibility, safety
 Peers, Media, Elites (politicians, doctors, industry) 
POLITICS
 Performance  POLICY
 experienced and perceived
 egocentric and sociotropic
Based on: Maioni A (2002): Is public health care politically sustainable?,
Presentation for the Canadian Fundation for Humanities and Social Sciences;
and
DETERMINANTS

35. 2005
RECENT TRENDS
 Its role is expanding...
 In health policy: ideas, evidence, leadership
 In health politics: conflict over resouces, deciding on rules
and responsibilities, battle for public opinion
... Due to increased salience & more informed citizens
(Maioni, 2002; reference in previous slide)
 Its shape is changing...
 Increased perception of crisis (finance, access, quality)
 Satisfaction with medical care received high
 Stable or expanding core values: HC as a social right
 Media and industry more influential; doctors & peers less;
government depends
 More educated = autonomous citizens?

36. 2005
DETERMINANTS OF SUPPORT FOR STATE
INVOLVEMENT,
24 OECD countries, ISSP 1997
PUBLIC UNEM. POLICY PUBLIC HC
INDIVIDUAL LEVEL
Woman .15* .09*
Age .004 .02*
Unemployment .36* .03
Egalitarian ideology .76* .37*
NATIONAL LEVEL
Unemployment .17* .12*
National ideology .29* .03
Source: Blekesaune M and Quadagno J (2003): Public attitudes towards welfare
state policies: A comparative analysis of 24 nations, European Sociological
Review, 19, 5: 415-427.

37. 2005
PO: SUMMARY & CONCLUSIONS
 Public opinion (citizens’ preferences and perceptions)…
 Plays a critical role in democracy: responsiveness, accountability,
quality of democracy
 Is also useful as a HC input & outcome + to track process
 Sits at the centre of politicians’ utility functions, and is a critical
determinant of public policy (veto)
 Is increasingly the target of IGs public opinion campaigns
 Requires active political mobilization, information and shared decision-
making to become an effective, independent force
 Future challenges
 Should the state invest in guaranteeing an independent, effective PO?
How? Media anti-trust policy & citizens’ associations?
 Should the state counterbalance IGs’ media campaigns? How?
 A substantial public investment in data, information and research on
PO (and professionals’ one!) is required
 Analysis of routine national series is a high priority

38. 2005
 At the aggregate level, the decision to engage in
collective action depends on
 1. the intensity of political conflict across social cleaveages
(class/income, religion/values, community/ethnia), ideologies and
political issues (social structuralism) and ...
 2. the extent to which there are political elites/organizations who
actively mobilize (and represent) their constituencies (power
resources theories  actor/action);
 3. ... which in turns depends on the extent to which state policies
grants equal political & social rights to under/priviledged groups
(policy feedbacks)
 4. the openess of democratic institutions to direct political
participation (institutionalism), eg voting regulations,
neocorporatism, popular legislative initiative, referendum
NOTE: Olson’s thesis are compatible with all the above
WHO PARTICIPATES?