Law  - Fall 2009
Racism, Health Disparities, and the Law
Professor Vernellia R. Randall
The University of Dayton School of Law

 Social Policy is Health Policy is Law


Some Difficult Problems in Health Policy

Rising Wealth Inequality: Why We Should Care

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"There is an Axis of Evil,  An Axis of Evil of inequality, of racism, of poverty, of economic deprivation
 that is adversely affecting the health of the American people." David Williams


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Health Equity Search


Mark Schlesinger

Mark Schlesinger, Some Difficult Problems in Health Policy , 30 Journal of Health Politics, Policy and Law (December, 2005)


No one promised that health care policy would be easy. The national governments with the longest track record--Germany, the United Kingdom--have been at it for about a century, producing a legacy of contentious policy disputes. Another cohort of countries began their lessons in the hard-knocks school of health-policy making during the 1930s; many more had enrolled by mid-century. During the latter part of the twentieth century, transnational organizations such as the World Health Organization (WHO) and the World Bank sought to accelerate the learning curve by identifying promising policies and promoting their diffusion across national borders. A substantial body of academic research now describes, diagnoses, and prescribes policies affecting nations' health care systems.

Despite all this accumulated experience and analysis, health-policy making does not seem to be getting any easier. Even in countries at the top of the WHO's ranking of effective and equitable health systems, national policy seems to be in constant state of flux, beset by citizens still insecure about their medical needs and expenses (Blendon et al. 2003), besieged by clinicians clamoring for additional resources (Moran and Alexander 1997), and bothered by government ministers convinced that excessive medical spending erodes their government's ability to address other vital societal needs.

Past scholarly work has identified some of the sources of these persisting*996 tensions. A continual influx of new technologies, layered atop prior generations of treatments that are never entirely displaced, creates inexorable pressures to expand spending, makes medical care complex beyond the ability of most patients to coherently assess, and outstrips the capacity of medical research to establish an evidentiary base for safe and cost-effective treatment. The life-threatening aspects of many medical conditions, coupled with the public's persisting ambivalence about the meaning of a good life and death, make it difficult to discern which allocations of scarce medical resources would be most equitable. Even our most basic conceptions of what it means to be healthy at various stages in life remain in flux, as limitations once accepted as normal are challenged by new treatment technologies or changing social norms about appropriate community engagement.

The articles in this issue of the Journal of Health Politics, Policy and Law direct our attention to two additional sources of persisting policy tension. The first three essays focus on some common challenges of health system governance, documented in three very different political cultures. Per L greid and colleagues write about hospital reforms in Norway. Miriam Laugesen assesses efforts during the early 1990s to introduce market reforms in countries with national health service (NHS)-style health care financing systems, with a detailed focus on the experience in New Zealand. Soonman Kwon and Michael Reich describe and contrast three reforms to health care finance in South Korea. Despite the different contexts and ostensible objectives, there are some striking parallels in these three reform narratives, which I'll describe a bit further below.

The two other essays in this issue also touch on a major challenge for contemporary health policy. These two are also related to one another, albeit in ways rather different from the connections among the first three essays (hence the dual cartoons introducing the issue). These final two essays explore different aspects of the social determinants of health. Jennifer Mellor and Jeff Milyo assess the impact of social capital on health, taking more careful account of the interactions between social capital and individual socioeconomic status. David Low and colleagues review the literature linking education and health outcomes. They try to extract from these empirical findings lessons for recasting public policy outside of medical care in a health-enhancing manner. In this case, the commonality between the two essays is not so much their current content. Rather, it involves possible future efforts to translate the empirical findings from the social capital literature into policy responses, much as Low and his coauthors have proposed regarding education.

*997 The Challenges of Health System Governance

More than most public policy domains, health care challenges policy makers with its multiplicity of goals. A well-functioning health care system must be responsive to the needs and concerns of individuals (patients, clinicians) while also taking into account collective interests in health and medical care. The WHO describes the balancing between individual and collective objectives as the "stewardship" function in health care systems (Travis et al. 2003), yet this term does not adequately capture the complex challenges that inhere in this balancing act. The task of striking the most appropriate balance between individual and collective interests across a variety of health services can be daunting in itself. In addition, policy makers must determine how best to identify and define the public good in health matters.

As illustrated in the first three essays, there are two central tensions in defining the collective interests in health policy. The first involves the articulation of the public interest. This task could be delegated to technical experts--policy analysts, government bureaucrats, or health professional interest groups. (Physician groups played this role as technical policy advisers in many countries during the mid-twentieth century, but were gradually displaced by analysts and bureaucrats as considerations of cost and efficiency grew more salient in health policy discourse.) Alternatively, collective interests can be articulated through political institutions: elected politicians in national or provincial legislatures or boards of governors or county councils at the local level.

The second tension involves the appropriate scope of the collective perspective. Are notions of the public good best conceived in health and health care matters for the country as a whole? Or might they be more sensibly articulated in a decentralized manner, in the form of more localized communities defined by geography, shared work settings, or some other common bond?

These tensions play themselves out in different ways in the health reforms in South Korea, New Zealand, and Norway. In the first two countries, the legitimacy of public involvement trumps, for at least some key policy decisions, the purported efficiency benefits from placing bureaucrats or enterprise managers in charge of allocating health care resources. By contrast, efficiency concerns seem to carry the day in policy discourse in Norway. In New Zealand, a preference for decentralized collective choice overrides the push for central accountability over medical spending,*998 whereas in South Korea the opposite appears to be true. Norway falls somewhere in between, maintaining a (possibly fragile) balance between central and local accountability.

Although the outcomes and the rhetorical labels in these reform debates differ across the three countries, in each country policy makers struggled to find a policy equilibrium that could balance competing forms of collective accountability. In all three countries, the shape of broader political institutions had a fundamental influence over the resolution of these tensions, providing mechanisms for the mobilization of interests, avenues for conveying their concerns into political debate, and narratives for assigning blame and responsibility for the negative and positive consequences of the reform process.

Equally striking is the extent to which policy makers drew on conceptions of government reform from outside medical care to guide their thinking about health care reform. In all three countries, broader conceptions of reenvisioning government found their way into health policy debates. This cross-domain diffusion of ideas can be a vital stimulus for innovative health policy, but only if policy makers are cognizant of the ways in which reforms will play out differently in health care settings. Laugesen's review of the New Zealand experience suggests that policy makers there were insensitive to these differences, undermining the legitimacy of their reform initiatives. Readers might consider whether these same concerns might have been influential in either Norway or South Korea.

Designing Policy to Address the Social Determinants of Health

The final two essays in this issue focus on two social determinants of health: social capital and education. We are at very different stages in our understanding of the connection of each to health outcomes. As Low and colleagues describe, the correlation between health and education has been long established in empirical research, which has also identified a variety of pathways through which this influence might occur. The challenge for health-policy making, at this point, is to take these documented pathways and make something of them.

In contrast, researchers have only begun to map out the empirical relationships between social capital and health. The earliest research establishing these connections is about a decade old. It is even more recently that researchers established that the various components of social capital--the nature of social networks, the attitudinal properties of those relationships,*999 and the resources embedded in the networks--influence health in distinctive ways. And as the Mellor and Milyo essay illustrates, we are only now beginning to explore how the impact of social capital interacts with other social determinants of health, such as individual income.

Each of these final two essays poses challenges for the other. Consider first the implications of the article by Low et al. for researchers who study social capital. To date, the focus of research linking social capital and health has been to establish how social capital matters, how much it matters, and whether that influence varies among different measures of health and well-being. Imagine instead that social capital researchers began to ask themselves the questions that the Low article poses for the linkage between education and health. What sort of connections between social capital and health might be actionable from the perspective of policy makers? What groups might be most effectively targeted to leverage this relationship into socially desirable outcomes? Although these questions are not entirely at odds with the current thrust of social capital research, they would direct attention to different implications of that research and might identify entirely different relationships for testing. Arguably, this translation of social capital research from an epidemiological to a policy analytic focus is an important next step in the evolution of this field of research.

Although research linking social capital to health is of relatively recent vintage, it holds some important implications for those deploying policies based on the connection between health and education. Most strikingly, social capital research has been powerfully attuned to the questions of whether social determinants of health operated primarily at the individual or community level (or both). As the essay by Low and colleagues reveals, research on education and health has typically presumed that education is most appropriately seen as an attribute of an individual (or individual household).

But this presumption may be flawed and may lead to flawed policy prescriptions. For school-aged children, we know that educational attainment is powerfully shaped by the resources their communities are able to muster to support the public schools. For adults, we know that residential choice often leads to affiliative sorting, producing strong correlations between individuals' educational attainment and that of their neighbors. Consequently, the effects of education on health may be, to a degree not fully explored in past research, a function of neighborhood or community-level characteristics. If true, this could fundamentally reshape the policy lessons that one extracts from the connection between education and health outcomes.

*1000 Social Determinants of Health and the Challenges of Governance

At first blush, it is hard to imagine two sets of articles more different than the two incorporated into this issue. One focuses on the politics of medical care reform in foreign countries and the other draws on the social determinants of health in the United States. Nonetheless, I believe that the first set of articles holds at least one important lesson for the second set. More specifically, the first three articles highlight a tension that is likely to develop when policy makers seek to appropriately balance interventions based on the medical and social determinants of health.

Published assessments have noted how difficult it has been to induce government officials to make choices that are sensitive to the health implications of social policies and programs. The barrier most often identified in these articles involves the challenges of convincing program administrators whose primary mission is to improve public education, housing, or urban infrastructure that they should weigh health implications against their other, more central objectives (Lavis 2002; McGinnis, Williams-Russo, and Knickman 2002).

But the articles on health reform in Norway and New Zealand suggest a second tension--between collective goals articulated at the national level and those decided primarily at the local level. In many countries, public education and policies affecting social infrastructure (the sort that would address issues related to social capital) are matters left largely to local government. By contrast, outside of the Scandinavian countries, health policy matters are typically addressed at the national level. To be sure, there are some health services that are locally administered in most countries, such as hospitals in New Zealand, maternal health clinics in Japan, or the community health centers in the United States (Schlesinger 1997). But even in countries that have attempted more fundamental decentralization of health care spending decisions, this is typically done through regional authorities, rather than local governments (Hunter, Vienonen, and Wlodarczyk 1998).

This creates a potentially problematic inconsistency. How can one strike appropriate trade-offs between the health consequences of spending on, say, public education compared to medical care, even if both systems are publicly financed, when the budgets for the first are set locally and for the *1001 second nationally (or even regionally)? How does one establish the appropriate boundaries between technical expertise and democratic accountability when these trade-offs are made in very different political contexts? These tensions are reduced in countries that have either local control of medical spending or national budgets for public education. But as illustrated herein for hospital reform in Norway, even in these contexts there is a persisting tension between local and national accountability, likely to play out differently in medical care and other policy domains. The broader implications of these inconsistencies I leave for readers to decipher.


      Blendon, Robert, Cathy Schoen, Catherine DesRoches, Robin Osborn, and Kinga Zapert. 2003. Common Concerns amid Diverse Systems: Health Care Experiences in Five Countries. Health Affairs 22(3): 106-121.

      Hunter, David, Mikko Vienonen, and W. Wlodarczyk. 1998. Optimal Balance of Centralized and Decentralized Management. In Critical Challenges for Health Care Reform in Europe, ed. R. Saltman, J. Figueras, and C. Sakellarides, 308-324. Buckingham: Open University Press.

      Lavis, John. 2002. Ideas at the Margin or Marginalized Ideas? Nonmedical Determinants of Health in Canada. Health Affairs 21(2): 107-112.

      McGinnis, J. Michael, Pamela Williams-Russo, and James R. Knickman. 2002. The Case for More Active Policy Attention to Health Promotion. Health Affairs 21(2): 78-93.

      Moran, Michael, and Elizabeth Alexander. 1997. Technology, American Democracy, and Health Care. British Journal of Political Science 27: 573-594.

      Schlesinger, Mark. 1997. Paradigms Lost: The Persisting Search for Community in U.S. Health Policy. Journal of Health Politics, Policy and Law 22: 937-992.

      Travis, Phyllida, Dominique Egger, Philip Davies, and Abdelhay Mechbal. 2003. Towards Better Stewardship: Concepts and Critical Issues. In Health Systems Performance Assessment, ed. Christopher Murray and David Evans, 289-300. Geneva: World Health Organization.

01 Defining Health                             x
02 Health Disparities                                   x
03 Health Policy & the Law
04 Wealth Inequalities                                  x
05 Racial Inequality                            x
05 Racial Inequality                            x
06 Physical Environment
07 Health Care Disparities                                  x
08 Pulling it together                                              x


Related Pages:
Home ] Up ] Overview of Health Policy (pdf) ] The Changing Scope of Health Policy ] Policy Strategy: Health Disparities ] Can Education Policy Be Health Policy? ] [ Some Difficult Problems in Health Policy ] Backgrounder 2: Closing the gap in a generation - how? ] Key Concepts - Social Determinants of Health ] Promote Better Working Conditions ] Improve Education ] Improve Conditions for Children ] Improve Food Security and Quality ] Assuring Healthy Physical/Built Environments ] Improve Public and Sustainable Transportation ]
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Home ] Syllabus ] Defining Health ] Disparities and Social Determinants ] Health Law and Policy ] Removing  Income and Wealth Inequalities ] Improving Racial Inequality ] Eliminating Health Care Disparities ] Pulling It All Together ]
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