The Welfare Regime Debate and Health Care Provision: Do we need a Southern Regime Type?
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Manufacturers and other businesses cater to consumer demand for products and services that may not optimize health e.
Another systemic explanation considered by the panel is whether there is something unique in how decisions are made in the United States, in contrast with other countries, which might produce different policy choices that affect health. Not all of the problems identified in this report are affected by policy decisions—many relate to individual choices or perhaps the inherent nature of life in America—but decisions by government and the private sector may play a role in shaping many of the health determinants discussed throughout this report. The relevance of public policy to health is perhaps most conspicuous in relation to recognized problems in the U.
But the potential causes of the U. People are responsible for their individual behaviors, but individual life-styles are also influenced by the policies adopted by communities, states, and national leaders Brownell et al. The obesogenic environment reflects decisions by the food industry and restaurants about the content and sizes of their offerings; business strategies about where to locate supermarket chains and fast food outlets; ballot decisions on parks, playgrounds, and pedestrian walkways; school board policies on high-calorie cafeteria menus and vending machine contracts; and the marketing of electronic devices to children Brownell and Warner, ; Institute of Medicine, , b, c, c; Nestle, Public- and private-sector policies affect drinking and driving, binge drinking, prescription and illicit drug abuse, and the use of contaminated needles by injection drug users.
Policies can also influence access to contraceptives and firearms. Both the incidence and lethality of injuries are affected not only by personal choices, but also by decisions made by manufacturers, builders, lawmakers, and regulatory agencies that control product safety, road design, building codes, traffic congestion, law enforcement of safety regulations e.
Policies also affect the social and economic conditions in which people live, and the quality of education—from preschool through college and professional schools Bambra et al. Political and economic institutions, which help drive the economic success of nations, are subject to a range of public policies Acemoglu and Robinson, Tax policy and decisions by employers, business leaders, government, and voters affect job growth, household income, social mobility, savings, and income inequality.
They determine the strength of safety net and assistance programs and the quality of the environment, from its physical characteristics e. The relevance of macroeconomic government policies on health was exhibited in a natural experiment when East and West Germany unified in after unification, the mortality rates for the elderly in the eastern part of the country declined to those of the western part Scholz and Maier, ; Vaupel et al. Notwithstanding the importance of addressing the causes of the U. Policies that affect public health, education, and the economy are themselves shaped by the institutional arrangements in a society—the governmental and nongovernmental arrangements that organize social relations, rank people into social hierarchies, assign worth, structure employment and the labor market, and address working conditions Bambra and Beckfield, As illustrated in Table , some studies of what has been described as the political economy of health Muntaner et al.
These influences are multilayered and complex. Figure presents a model by Hurrelmann and colleagues , which illustrates the multitude of social and political factors that contribute to population health and, by extension, to cross-national differences in health. The U. Esping-Andersen, Most European welfare programs came into existence after World War II with the goal of providing more universal access to assistance Bambra and Beckfield, The social democratic model promotes social equality through wage compression, organized through strong collective bargaining by unions, and tax policies that direct resources to the social security system Bambra and Beckfield, As detailed in Part I of the report, the Scandinavian social democratic countries generally have higher health rankings than the United States, along with more favorable measures of social and economic well-being.
As a group, these social democratic countries report longer life expectancies, lower infant mortality rates, and better self-rated health than do liberal countries, including both the United States and the United Kingdom Bambra, , ; Chung and Muntaner, ; Coburn, ; Eikemo et al.
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Figure shows that this pattern has existed for decades Conley and Springer, Sociological research is beginning to suggest that the style of governance in a country may exert its own influence on health outcomes, independent of individual-level variables. Another study concluded that the model type predicted approximately 20 percent of the difference in infant mortality.
For example, mortality rates in Denmark approach those of the United States, and Finland has high mortality rates for some conditions.
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However, the panel notes the limitations of current evidence on this topic, which relies heavily on cross-sectional associations. Controlled trials to produce more definitive evidence would be untenable, and all studies on this subject must cope with a variety of methodological challenges, such as the potential endogeneity of the political and social environments, as well as issues relating to aggregate efficiency, intertemporal dynamics, and macroeconomic effects.
Typologies for regimes, such as welfare states, can be blunt measures that require further refinement to properly differentiate policy nuances across and within countries and to. For example, social democratic countries like Sweden had low infant mortality rates early in the 20th century Regidor et al. There is little question that the European welfare model is effective in redistributing income and reducing poverty.
More universal and generous welfare systems achieve greater income equality than other systems through more generous income transfers through taxes and services Esping-Andersen and Myles, These entitlement benefits may buffer the health effects of material deprivation and thereby improve health outcomes but they may have other consequences that are not economically or politically viable in the United States. Related characteristics of Scandinavian society, such as greater gender equality Stanistreet et al.
Political empowerment of minority groups and women appears especially important to health Beckfield and Krieger, As noted in Chapter 7 , citizen engagement in the United States, such as voting in elections, is lower than in most other OECD countries e , and the United States has one of the lowest rates of female participation in the national legislature Congress Armingeon et al.
Scandinavian society is also known for having less income inequality than in the United States see Chapter 6 , a likely product of the welfare state. The Luxembourg Income Study provides evidence that social democratic policies have, over time, substantially reduced income inequality Alderson and Nielsen, The Scandinavian welfare programs universalism, generous wage replacement rates, extensive welfare services may also narrow income inequalities and provide low-income individuals with greater access to services Coburn, However, as discussed in Chapter 6 , it remains unclear whether income inequality itself, or the policies that affect income inequality, bear more on the U.
There is some evidence to suggest that aggregate spending on social programs is associated with better health. One study examined spending. No single country adheres to all aspects, and there is internal policy variation within individual welfare states and among the countries of each welfare state regime Bambra, More importantly, the study found a significant association between social spending and life expectancy, infant mortality, and potential years of life lost Bradley et al.
In a commentary about the U.
Authors of another study also noted that the United States ranks poorly on measures of full-time employment, public child care, union representation, and parental leave Pettit and Hook, see Table Many of these may be less acceptable in the United States because of related tax burdens and other implications. In seeking a systemic cause for the U. We have suggested a potentially promising line of inquiry based upon differences in social policy contexts. However, the challenge is obviously to identify the particular social and labor policies that have a causal impact on health and that may contribute to cross-national health differences.
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For example, do the more generous parental leave policies in Europe contribute to their comparative health advantage? Have employment protection policies contributed to the better health of European workers compared with their U. The great variation in policy reform during the last 50 years across Europe and the United States provides us with a potentially fruitful set of natural experiments to consider. Broadening the scope of our inquiry to include the social and policy context of nations might help to solve the puzzle of the U.
Employment was classified as part time when a respondent reported 1—30 hours of work per week. Parental leave represents the maximum number of weeks paid or unpaid available.
Even the reduction in income inequality achieved by this form of capitalism probably results from the interaction and combination of multiple policies e. Nor is the social democratic model a panacea for public health. Compared with Scandinavian countries, health gradients tend to be lower in Bismarkian countries e. As discussed in Box , a variety of explanations for the paradox have been proposed Bambra, ; Dahl et al.
The United States can take little comfort in debates about why some European countries do better than others in reducing health gradients, because it is still the case that the United States and the United Kingdom generally fare worse than all of them—on both aggregate health status and the steepness of the health gradient Avendano et al.
As noted in Chapter 6 , at least one study has reported that the health gradient by education is steeper in the United States than in Western European countries Avendano et al. These cross-national comparisons certainly shed light on the U. Social, economic, and public health policies are often an expression of societal values, set against the backdrop of other exigencies e. Social rights were extended at minimal cost to the entire population in a social contract that sought to eliminate status privilege Bambra and Beckfield, One proposed explanation for the paradox of greater health inequalities in many Scandinavian welfare states is that lower social strata may have a higher relative concentration of individuals at increased risk of disease.
Decades of upward intergenerational social mobility may have increased opportunities for social selection and created more homogenous disadvantaged social groups with such characteristics as low cognitive ability and less favorable personality profiles.
The increase of intergenerational social mobility is due primarily to changes in the economy that have led to an expansion of higher education, but to the extent that welfare policies have contributed to making the education system more merit based, they may paradoxically have contributed to a widening of health inequalities Mackenbach, Another proposed explanation is that some European welfare states happen to be further in their epidemiological development, and have now reached the fourth stage of the epidemiological transition in which health improvement depends largely on behavior change Olshansky and Ault, This explanation increases the importance of nonmaterial factors—including cultural capital and such personal characteristics as cognitive ability in relation to health—that have become more socially differentiated because they have largely been untouched by the welfare state.
To the extent that welfare policies have contributed to making an affluent life-style widely affordable, they may have paradoxically contributed to a widening of health inequalities Mackenbach, Hurrelmann and colleagues raised the following hypothesis in their call for further research on the paradox , p.
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In economic terms, this is tantamount. Conversely, the limited state welfare assistance that exists in East Asian countries Hong Kong, Singapore, South Korea, Taiwan, and sometimes Japan —which rely instead on the family and voluntary sector for the social safety net—reflect Confucian social ethics, such as obligation for immediate family members, thrift, diligence, and a strong education and work ethic Aspalter, ; Bambra and Beckfield, ; Croissant, ; Walker and Wong, As a consequence, health-promoting strategies within the family, leisure and work settings may be neglected or deemphasized in the social democratic countries.
Some of these international patterns can probably be explained by between-country variations in the social patterning of health-related behaviors, such as smoking and alcohol consumption. In the Scandinavian countries, inequalities in mortality from smoking-related causes such as lung cancer and chronic lung disease and from alcohol-related causes tend to be larger than in many other Western European countries Mackenbach et al.
Survey data show that inequalities in smoking are larger in the north and west of Western Europe than in the south Cavelaars et al. These geographic patterns reflect differences between countries in the progression of the smoking epidemic: countries in Southern Europe tend to be at an earlier stage in the progression, in which smoking is not yet as strongly socially patterned as in later stages Lopez et al. There is also some evidence to suggest that cross-national variations in inequalities in access or quality of health care may play a role. Socioeconomic inequalities in mortality from conditions that are amenable to medical intervention are particularly large in Eastern Europe Mackenbach et al.
This proposed explanation would also need further confirmation.
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On issues that pertain directly to the U. The United States ranks poorly on a number of factors that could explain its health disadvantages. As detailed in Chapters 4 - 7 :.