Political Ideologies, Institutions, and Health: The Role of Privatization
Image: “Interest’s Conflicts” by David Goehring. CC 2.0
“It is very hard to talk about a middle ground for something that is a fundamental right.” – Teri Reynolds on health care reform, The Obama Syndrome: Surrender at Home, War Abroad1
When illness befalls us, we refer almost instinctively to questions concerning our diet, exercise, or who we last made contact with. Our search for its treatment then immediately turns to doctors and medication. While these day-to-day decisions certainly affect our health, they reflect cases of individual health. More importantly, they are actually determined by larger political and economic factors that concern entire systems – factors that, for instance, determine how many doctors are available or whether we can afford to see one. To assess the influence of systemic factors requires tracing the fundamental nature of a society’s political system – its political ideology – population health, through labour markets, welfare states, and health care systems.
A cross-national examination of the United States and Sweden, the former with a liberal political ideology based on capitalism, and the latter consisting of social democratic ideology with social egalitarian principles, demonstrates the influence of political ideology on health. Central to this analysis is the expansion of privatization into healthcare within a liberal political ideology – a growing trend referred to as “Big Med”2, where health services are consolidated under the administration and jurisdiction of large corporate entities. The deleterious effects of this expansion are realized in population health through policies and bureaucratic structures in health care.
Political ideologies of parties in power influence all levels of society by controlling political institutions3. This consequently influences health through social and economic policies from the welfare state to the organization of the labour force. Within OECD countries, four major political ideologies exist in a gradient of adherence to redistributive policies: social democratic, conservative, liberal, and authoritarian conservative (dictatorship)3. Most common among these are the liberal and social democratic ideologies.
Founded on the tenets of free market capitalism and individualism, liberal political ideology (i.e. the United States) is often distanced from egalitarian, redistributive principles. Hence, a privatization trend emerges from within this political ideology as capitalism’s influence on politics grows. Privatization of the health care system has profound impact on health by emphasizing private management of health care quality and reform, rather than public funding, thereby limiting access to quality care for some economic classes.
The United States exemplifies the most significant forms of privatization, even within the category of liberal political ideology. Efforts to expand health coverage in the US, such as the recent Affordable Care Act, or “Obamacare”, has met strong resistance from leaders devoted to a model of free market capitalism4. Thus, movement toward equitable policies are curbed by political motives at a higher level, which in turn align with the theme of privatization. While it may be said that “Big Med” offers patients greater control over their treatment, the costs required in a privatized healthcare setting have limited access to treatment for everyone save the rich. The inequality embedded in this trend is made plain in an expanding bifurcation of health in the US, where people are reported to be either very healthy or very unhealthy5.
By contrast, social democratic countries (i.e. Sweden, Denmark, Norway) tend to commit to more socialist policies with high public health and social service expenditure, and that promote labour movements. These give rise to beneficial working conditions and facilitate better health outcomes through improved working conditions, health benefits, and more equitable pay that can reduce overall income inequality6. Sweden, for example, ranks first out of 19 OECD countries in standardized death rates by preventable/treatable causes7, has a healthy population by international standards8, and has scored high on three disease-based comparisons (ischaemic strokes, breast cancer, and heart attacks9-11) of health-sector outcomes. Sweden’s bureaucratic structures and policies permit a more egalitarian health care system, resulting in better health outcomes.
The Swedish system is decentralized, such that county councils decide what operational structures are best. This allows for a flexible and innovative healthcare model, in which the provision of primary care has shifted from general practitioners (GPs) to multidisciplinary centres8. Through decentralization on a systematic level, individual clinical centers are given more autonomy, enabling patients more choice in their treatment in terms of choosing their preferred primary care clinic, GP, and hospital8. In contrast, the same amount of choice is only available in a privatized system to people rich enough to afford it.
Another aspect of this system is that by concentrating on clinical evidence through the use of registers (databases containing individualised data on diagnoses, treatment, and outcomes)8 it has been possible to develop more rigorous assessments of treatments. This includes medical and cost-effectiveness analyses that are open access, contrary to often hidden data in privatized systems. Institutions are thus driven to perform better, while stronger partnerships are created between research and clinical institutions to identify optimal approaches in medicine8. However, structural limitations in Sweden continue to exist primarily in improving access to primary care rather than hospitals, preventing fragmentation from decentralization, expanding reforms to a national-level, and achieving financial sustainability8.
Nevertheless, difficulties derived from financial sustainability for universal health care do not necessarily warrant endorsement of privatized health care as an alternative. The costs of private health insurance overhead in the U.S., for instance, has been found to vastly exceed that of government programs: the provision of universal health care in the U.S. would cost roughly $300 billion, in contrast to privatized health care, which costs $400 billion according to conservative estimates12. Moreover, government programs have been found to be at least ten times more efficient than private insurance. Hence, in spite of financial difficulties for supporting universal health care as in Sweden, we should not feel compelled towards the assumption that privatization or “Big Med” is a more viable alternative in our search for a solution.
In conclusion, the influence of political ideology ripples across labour markets, welfare states, and health care policies to impact the health of individuals. By comparing Sweden and the United States within OECD countries, we discover that a social democratic political ideology, in the former, is associated with better health by establishing egalitarian policies that proffer better working conditions and more choice in treatment. In stark contrast, a liberal political ideology, grounded on free market capitalism, as in the United States, is more likely to impair health by reducing spending on services, allowing exploitative labour conditions, and facilitating privatization in health care that compromises access to treatment.
References
Reynolds, T. & Ali, T. (2010). The Obama Syndrome: Surrender at Home, War Abroad. Brooklyn, NY: Verso Books.
Moses, H., Matheson, D. H. M., Ray Dorsey, E., George, B. P., Sadoff, D., & Yoshimura, S. (2013). The Anatomy of Health Care in the United States. Clinical Review & Education, 310(18), 1947-1963.
Navarro, V., Muntaner, C., Borrell, C., Benach, J., Quiroga, A., Rodriguez-Sanz, M., Verges, N., & Pasarin, M. I. (2006). Politics and health outcomes. Lancet, 368, 1033-1037.
Schroeder, S. A. (2013). Physicians, Politics, and Health Insurance Expansion. Journal of General Internal Medicine, 29(2), 267-268.
Pylypchuk, Y. & Sarpong, E. M. (2013). Comparison of Health Care Utilization: United States versus Canada. Health Services Research, 48(2), 560-581.
Burgard, S. A. & Lin, K. Y. (2013). Bad Jobs, Bad Health? How Work and Working Conditions Contribute to Health Disparities. American Behavioral Scientist, 57(8), 1105-1127.
World Health Organization. (2000). The World Health Report 2000, Health Systems: Improving Performance. WHO, Geneva. Retrieved from: http://www.who.int/whr/2000/en/whr00_en.pdf?ua=1
Rae, D. (2005). Getting Better Value for Money from Sweden’s Healthcare System. Retrieved from OECD: http://www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?doclanguage=en&cote=ECO/WKP(2005)30
Moon, L. (2003). Stroke Treatment and Care: A Comparison of Approaches in OECD Countries. Chapter I.3 in A Disease-based Comparison of Health Systems: What is Best and at What Cost? (Pp. 53-76) OECD, Paris. Retrieved from: http://browse.oecdbookshop.org/oecd/pdfs/product/8103031e.pdf
Hughes, M. (2003). Summary of Results from Breast Cancer Disease Study. Chapter I.4 in A Disease-based Comparison of Health Systems: What is Best and at What Cost? (Pp. 77-94) OECD, Paris. Retrieved from: http://browse.oecdbookshop.org/oecd/pdfs/product/8103031e.pdf
Moïse, P. (2003). The Heart of the Healthcare System: Summary of the Ischaemic Heart Disease Part of the OECD Ageing-Related Diseases Study. Chapter I.2 in A Disease-based Comparison of Health Systems: What is Best and at What Cost? (Pp. 162-179) OECD, Paris. Retrieved from: http://browse.oecdbookshop.org/oecd/pdfs/product/8103031e.pdf
Metz, S. (2014). Implementing a Universal Healthcare System Costs Less, Provides Better Care. The Lund Report. Retrieved from: https://www.thelundreport.org/content/implementing-universal-healthcare-system-costs-less-provides-better-care