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Solving the Health Care Problem. How Other Nations Succeeded and Why the United States Has Not
Pamela Behan
ISBN: 978-0-791468-37-1 2006 172 pages State University of New York Press
Peter Woodley
The health system of the United States stands out amongst those of developed economies on two grounds: its cost and the lack of a universal health insurance program. In this short book Pamela Behan sets out to explore ‘... why the United States does not guarantee its citizens access to health care or protect them from its costs'. Devoting about as much attention to describing theory and method as to analysing and comparing three health care systems (the United States, Canada and Australia), Behan starts with a thorough introduction, canvassing a range of theories for explaining the direction of public policy. The author settles on some particular theories to test, and examines the comparative method of policy analysis. In general, Behan puts aside theories which attribute outcomes of policy to single casual factors, and focuses on what might be considered two classes of theory to be applied to the comparative analysis that follows. The first she describes as political institutional theories: approaches that stress the roles of the structures of government in shaping policy. The second Behan describes as ‘power resources theory', a class-based view of history and society, calling attention to ‘the balance of politically useful resources controlled by the capitalist and working classes in a given society' (2006: xiv).
While the author invites readers to skip this chapter and to launch into the descriptions and analyses of the three health care systems under review, I found this introduction of the problem, the theory and the method to be the most interesting and useful part of the book. It is concise and well structured.
The core of the book consists of three chapters, each describing the evolution of health care financing policy in the countries under review. Drawing largely on a narrow range of reputable secondary sources, each chapter describes briefly the history of settlement and the development of government before outlining the major turning points in the processes by which the respective colonial, then provincial/state and federal governments defined their roles in financing health care. Each of these chapters ends with an analysis of the factors that led to a system of ‘national health insurance' (Canada and Australia) or prevented such a system from being adopted (the United States).
Each case study bears out the influences of political institutions and the distribution and utilisation of power that the introductory chapter foreshadowed. In her analysis of the Canadian experience, the author highlights the effect of third political parties in the emergence public health insurance at provincial and federal levels, and the relative lack of veto points, that is, institutional barriers to the enactment of the aspirations of executive government. The chapter on Australia highlights the several cycles of building and dismantling public health insurance since the Second World War as being a unique feature of that country's health financing policy. The author concludes this chapter with the view that decisive factors leading to the introduction of public health insurance in Australia have been the ‘political polarisation of Australian society' (2006: 33), as well as the creation of the Australian Labor Party and the opportunities presented by the parliamentary system for parties with a majority to implement their policies. The chapter on the United States concludes with the assessment that national health insurance has not been implemented because of the failure of political labour parties to thrive, the obstacles presented by veto points within political institutions, and the consequent opportunities for powerful interest groups to impede reform.
Each case study is contained in around thirty pages. This presents a considerable challenge, to describe and analyse attempts - successful and otherwise - to negotiate and implement often quite diverse and complex policy in different political and social settings. To a student exploring health financing policy in these countries for the first time, these chapters are a useful introduction: a point from which to follow up more specialised references. However, to readers with some knowledge of one or more of the health systems under review, in their brevity, the chapters may seem to gloss over, if not distort, some important aspects of policy development. For example, the chapter on Australia gives only the most cursory mention to the creation of the Pharmaceutical Benefits Scheme. Coverage of the period since 1996 is confused, which is unfortunate because it would add further weight to the author's broader conclusions if it were adequately analysed.
The final part of the book applies a method known as Qualitative Comparative Analysis to the question of what factors lead a country to adopt universal health insurance, or prevent such a development. This method involves using Boolean algebra to demonstrate an association between a range of causal factors and certain policy outcomes, expressed as either a positive or a negative event. In this case, the positive event is the implementation of ‘national health insurance' (NHI), and the negative is an event that falls short of full implementation. To increase the power of this analysis, the author identifies 19 cases over time from the three countries in question. Behan concludes that there must be one of two sufficient conditions in place for NHI ‘success': either a lack of veto points, or labour party power. The analysis also identifies four necessary conditions: federal power in the health policy arena; a multiparty system; a legislative legacy; and strong trade unions. If the book has an overarching conclusion it is that social policy is more complex than ids generally theorised (2006: 118).
Students of comparative policy analysis will find this a concise and useful study. The methods - both traditional and Qualitative Comparative Analysis - are clearly described in the body of the book, with more detail of the latter in appendices. Students new to the history of health care financing in Canada, Australia and the United States might find each of the case studies a useful introduction, but should be encouraged to read more extensively if they have a particular interest in one health system or another.
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