Introduction: Varieties of Comparative Analysis in the World of Medical Care Policy

Background 1

The world of medical care is no stranger to cross-national commentary. Scientific claims, data, and concerns about new drugs, devices, and procedures fly around the world literally with electronic speed. Professionals jet off to distant lands to consult with colleagues – specialist physicians, administrators, regulators, policymakers, among others. And, in the field of health politics, policy and law, there has been something of an explosion in the cross-national dialogue, one conducted in seminars, conferences, journals, email communities, and consulting assignments. All of that was the topic of an article on the “field” of comparative policy analysis in health care published in this journal in December of 2005 (Marmor et al.). There the interest was to produce a portrait of the literature in this area, to suggest, as its title put it, the “promise and perils” of such scholarship. Following soon thereafter, Burau and Blank (2006) addressed the appeal and the limits of typologies in comparative health policy research, emphasizing the importance of “country-specific institutional contexts” that in turn make “health policies follow … highly complex and specific … trajectories”.

This special issue has a different focus: providing illustrations of a variety of ways to approach comparative analysis. It builds upon the claims of the earlier efforts at synthesis, but stresses instead just how conceptually and empirically varied are the options when one sets out to know how other national arrangements work, why they do, and what one might learn from such knowledge. The purpose of this introduction is to describe briefly the various (and intersecting) modes of comparative work that the following papers represent.

Before that, however, I want to note briefly the process by which this took place. As a longtime advocate of comparative policy analysis, this editor has been fortunate to have had contact with a substantial range of scholars in the field. Moreover, a number of those scholars have participated since 1994 in annual conferences on health policy developments in five industrial democracies: Germany and Holland, the United States and Canada, plus England. A collection of papers from those conferences will be published in 2009 by Yale University Press. The process of writing the introduction to that set of comparative essays in turn prompted attention to a wider set of issues, ones reflected in the range of topics to which we will turn. This journal responded to these developments by sponsoring a conference at Yale University in autumn 2006 when the first drafts of the articles here were presented and comments offered.

The Work Presented Here

Monika Steffen's essay on French and German medical care arrangements offers an appropriate starting point. The topic she addresses is whether a common categorization of a welfare state – the continental model typically called Bismarkian – helps or hinders one's understanding of the evolution and current state of health policy affairs in France and Germany. Her conclusion is that the category obscures more than it illuminates, blurring the observer's understanding of how differently these two particular systems developed over time. Her conclusion is that French policy over time has shifted authority to central state actors, weakened the social partners in labor and management (always less powerful than their German counterparts), and come to depend upon taxation (as against social insurance contributions). The result is an evolution to what she calls “liberal universalism”, which is so different from her portrait of German social insurance that she doubts the utility of the Bismarkian category in this field. Readers can make up their own mind about whether Steffen has convincing enough evidence for her conclusion. But, here is an example, well developed with historical evidence, of what we would rightly term comparison within categories rather than across them. Her essay leaves one with the impression of increased “hybridization” of familiar categories, which in turn highlights for comparative work (here and elsewhere) a potentially fruitful line of inquiry. Steffen's article illustrates forcefully the explanatory importance of country-specific institutional factors that the previously noted Burau and Blank (2006) article emphasizes. Beyond that, her conclusions both parallel and slightly diverge from our other example of using welfare state categories as a starting point: namely, the piece by Claus Wendt and Jüergen Kohl.

Claus Wendt and Jürgen Kohl combine a quantitative analysis of health financing and service provision in a number of countries with a more qualitative analysis of reform issues in three country cases. The detailed case studies are of three of the most commonly compared arrangements for medical financing, delivery, and quality: England, Germany, and the United States. These are presented as paradigmatic instances of systems with relatively strong roles for state hierarchy (UK), professional self-regulation (Germany) and private markets (US). Their aim is to work out a cross-national index of health care provision that is both innovative conceptually and reasonably operational in practice. Their thorough study provides grounds for concluding that largely self-regulating systems generate higher levels of providers at higher levels of cost. Systems of state control – illustrated by the NHS – lead both to lower levels of providers and lower costs. And market systems – exemplified by the United States – lead to lower levels of providers at higher cost levels. This triple finding, while not surprising about cost levels, puts into bold relief the issue of provision and is of considerable relevance to policy debates.

Presenting England as an ideal typical example of state control, Germany as illustrative of a self-regulating model, and the United States as the ideal typical market-dominated system is not, however, without its difficulties. As already noted, marrying typological categories to particular country experiences can distort as well as illuminate. So, for instance, Canada, with its relatively low levels of provider supply and comparatively high level of expenditure, is a “black swan” in the self-regulation category. As a categorization of health care structures, then, the Wendt and Kohl findings both illuminate and give one pause.

The article by Okma et al. is unmistakably innovative in country selection and striking in its findings. The six national cases – Chile, Israel, Singapore, Switzerland, Taiwan, and The Netherlands – are ones seldom grouped together for comparative purposes, located below the “radar screen” of most inquiry. On the one hand, they are all relatively small nations, but similar in only some dimensions. They do share broad policy goals – universal access to decent quality care and broad insurance coverage while restraining public expenditure – and they all have struggled with the common fiscal pressure of rising health costs. Beyond that, however, they are “most different systems” in the language of comparative analysis, with wide divergence in institutional design and political complexion.

The findings are fascinating in their conflict with universalistic claims in the comparative literature. All the countries addressed a similar range of reform options and all but one expanded public and private health insurance in recent decades. But all of the outcomes varied along three dimensions: namely, funding, contracting (including modes of payment) and ownership. This kind of comparative work treats the cases as permutations and combinations of obviously important dimensions of a health care polity. As one of the referees of this volume noted, this article illustrates another approach to “most different system analysis”, one that falls in line with the thread of “hybridization” that runs through this collection.

Gwyn Bevan's article illustrates the natural experiment mode of comparative work. It capitalizes on the changes with the UK's National Health Service that delinked England from the policymaking inclinations of both Scotland and Wales. Within broad parameters, these sub-national units were set loose and differences surely emerged. In that way, Bevan has provided a within country variant of comparative research, with a clarity about before and after findings that are hard to replicate. Bevan is particularly concerned with how one can make performance measures work. They must produce reliable information to have any reputational impact, they must be robust to withstand countering from those criticized, and they must be widely known and understood by the public. This work, then, is empirically based, of theoretical interest, and with practical relevance, a welcome and distinctive addition to the comparative literature.

At first glance the article by Joe White is puzzling, a single country commentary in a collection presented as variants of approaches to comparative inquiry in health policy. His aim is not to dwell upon the peculiarities of American politics or culture. Rather, it is to draw lessons of interest from the US experience based on the commonalities of the delivery and financing of medical care. White's premise is that “the US offers more evidence than in any other rich democracy about what might happen if ‘market forces’ were allowed greater influence”. The article places great emphasis on how capital is treated in so-called competitive models and warns reformers of how significant that is for the control of costs. This mode of externalizing lessons from a single, important case does, however, raise a persistent question in comparative analysis: namely, scale. The sheer size of the United States and its health care sector raises the issue of whether the pools of capital in play make the economic and political dynamics of the US health care arena different not only in degree, but in kind from smaller nations. Even with this caution in mind, the White paper exemplifies the diversity of approaches that mark this special issue.

The commentary by Jean de Kervasdoué– while engaging in comparisons of the United States and other industrial democracies – is of a quite different sort than White's reflections. The essay's major focus is methodological, concentrating on whether and in what ways “cross-national ranking and rating of public services [satisfy] the conditions for effective” policy learning. This leads to a discussion of the difficulties in measuring outcomes in relationship to stated goals. From there the essay takes up three related healthcare topics. One is the ways in which the dominant features of health and health care make meaningful comparison particularly difficult. A second section illustrates that claim by critically reviewing the (in)famous and widely disseminated ranking done by the World Health Organization in 2000. Finally, the essay contrasts the WHO mode of ranking with one based on a “more reliable indicator”, namely, life expectancy. The point of this effort is to provide for the nations of the developed world “quantifiable, objective data” for comparative evaluations. These data, according to Kervasdoué, are “relatively reliable, strikingly variable, and … challenging for some strongly entrenched policy ideas about the production of a population's health”. In this article we have an explicit emphasis on the promise and perils of cross-national policy learning, itself one of a variety of purposes to which such comparative policy analysis can be put.

The article by Richard Freeman and Lorraine Frisina continues the methodological theme of the preceding discussion. It could just as easily open the special issue as end it. Their emphasis is on the most fundamental aspects of description, explanation, and comparative inquiry. Their argument begins by examining once again the very role that classification and comparison play in intellectual life. They review the special senses in which “ideal types” have been used in social science and then turn to a sketch of what classificatory understandings have dominated the comparative analysis of national medical care arrangements. For the purposes of this special issue, it is this section that is most informative. Freeman and Frisina argue that classifications anchored in welfare state typologies – most associated with pension cash payments and widely linked to Esping-Andersen's (1990) Three Worlds of Welfare Capitalism– have regularly led to misrepresentation. To illustrate, they note that the United States is often wrongly described as a system of private insurance – the result of using a trichotomous categorization of national health services, social insurance arrangements, or private health insurance. They go on to note that these are binary categorizations when we can easily make the case that in finance, provision, and regulation, countries are not one thing or another, but hybrids. And that is precisely what this article emphasizes in its concluding remarks about comparison and complexity. For all the use of the term “systems”, the authors note, it is “remarkable how little [health systems] have been theorized in system terms”.

The discussion of classification, categorization, and comparison links, then, both the opening and the closing articles of this special issue. But, before closing this introduction, I want to review what might be called the other rules of cross-national policy analytic game itself. In short, I want to return us to the very purposes we can legitimately have for the comparative enterprise. Put another way, what are at least some obvious ways in which policy analysis might be improved by cross-national understanding. One is simply to define more clearly what is on the policy agenda by reference to quite similar or quite different formulations elsewhere. The more similar the problems or policy responses the more likely one can portray the nuanced formulations of any particular country. The more dissimilar, the more striking the contrast with what one takes for granted in one's own policy setting. This is the gift of perspective, which may or may not bring with it explanatory insight or lesson drawing. All of the articles in this special issue have this to offer.

A second approach is to use cross-national inquiry to check on the adequacy of nation-specific accounts. Let us call that a defense against explanatory provincialism. What precedes policymaking in country A includes many things – from legacies of past policy to institutional and temporal features that “seem” decisive. How is one to know how decisive as opposed to simply present? One answer is to look for similar outcomes elsewhere where some of those factors are missing or configured differently. Another is to look for a similar configuration of precedents without a comparable outcome. Here, the article by Okma et al. most vividly illustrates the benefits of this approach. Using the most different system design, that essay cautions precisely against both explanatory provincialism on the one hand and causal universalism on the other. As is obvious from the sketches, a number of the essays in this volume provide equal measures of protection from this intellectual vice.

A third and still different approach is to treat cross-national experience as quasi-experiments. Here one hopes to draw lessons about why some policies seem promising and doable, promising and impossible, or doable but not promising. This is obviously at work in reviews of experience with medical care costs across the OECD. The Wendt and Kohl essay, along with the White article, exemplify this line of cautious possible lesson-drawing.

All of these approaches appear elsewhere in the comparative policy literature and are noted in review essays (Klein 1991, Marmor et al. 2005). What has not been emphasized as much are gross mistakes in the use of comparative policy analysis. So, we end with a cautionary note about two perspectives that, when applied literally, are utterly misleading. One is what can be termed the “naïve transplantation” conception of cross-national learning. The idea is that one searches widely for “best practices” and assumes, if found, they can be transplanted without loss from site A to site B. There is plenty of this about in the professional literature, but no social science support for the claim that a practice in one site can be transplanted without adaptation to another. The opposite vice is what can be termed the “fallacy of comparative difference”. The major premise of the approach is the claim that if “any two sites differ from another factually, there is no respect in which they can learn from one another”. The factual premise is that there is always at least one respect in which two places (nations) differ. The syllogistic conclusion is that, therefore, no cross-national policy learning is possible.

The aim of this special issue, then, is to note the variety of purposes and modes that the comparative analysis of medical care policy justifiably can serve and illustrate. It is up to the reader to decide whether that task has been illuminating or needlessly tedious.

Additional information

Notes on contributors

Theodore R. Marmor

Ted Marmor is Professor Emeritus of Management at Yale, where he taught from 1979 to 2007. Among his writings are The Politics of Medicare (1970, 2000), America's Misunderstood Welfare State (with Jerry Mashaw and Philip Harvey), and, most recently, Fads, Fallacies, and Foolishness in Medical Care Management and Policy (2007). Marmor is now an adjunct Professor of Public Policy at Harvard's J.F. Kennedy School of Government.

Notes

1. Marmor et al. 2005, Burau and Blank 2006.