Ellen M. Immergut. Health Politics, Interests and Institutions in Western Europe

New York: Cambridge University Press, 1992. xxiii+336 pp. $49.95.
       Ellen Immergut has produced a first-rate scholarly study about how political institutions have affected health policies in France, Switzerland and Sweden. This book is timely for readers in the United States because it provides a comparative analysis of the evolution and politics of national health insurance (NHI). The main argument is that although the policy issues and interest groups affected by the passage of NHI bear a striking resemblance in France, Switzerland and Sweden, the evolution and outcomes of the process were very different due to the institutional design of the decision-making process in each country.
       All efforts to create a system of national health insurance have involved conflict between government as buyer and regulator of health services, and providers who resist the imposition of price controls and other forms of government intervention into their affairs. Immergut shows, through carefully crafted case studies, that the goals of policymakers and interest groups were quite similar in France, Switzerland and Sweden, and she suggests that the different outcomes reflect not so much different ideologies, or patterns of interest group demands, but rather differences in political institutions for decision-making.
       In France, the significant change in these institutions following the creation of the Fifth Republic in 1958 provides for a particularly rich case study. Immergut highlights the contrast in health politics between a parliamentary system with weak coalitions and a maze of interest groups and veto points before 1958, and a new constitution allowing for a powerful president following 1958. In Switzerland, the use or even the threat of national as well as local referenda has succeeded in constraining the role of the federal government in health care, and blocking successive attempts at the creation of compulsory national health insurance even after decisions had been made in the executive branch and approved by parliament. Finally, in Sweden, a strong executive branch in combination with a tradition of party loyalty and consensual agreements among major interest groups limited opportunities for parliamentary opposition and thereby enabled the establishment of NHI, controls on doctors' fees, and finally the creation of a national health service.
       As a contribution to scholarship in political science, Health Politics contains useful first and last chapters on the role of interests, class and institutions in the making of health policy. As a contribution to health policy, Health Politics leaves us with three excellent case studies on the evolution of national health insurance in France, Switzerland and Sweden. France and Switzerland, in particular, have received almost no attention from policy analysts who seek to inform American policymakers in the current debates about health care reform. This is unfortunate because both systems have virtually universal coverage, private fee-for-service practice, high rates of patient satisfaction, and some of the highest-quality medical care in the world. Moreover, both systems provide a rich source of lessons for policymakers in the United States.
       French NHI, like German and Japanese NHI, is an important model of a system financed on the basis of employer mandates (compulsory payroll taxes and direct premiums for agricultural workers and the self-employed) with no restrictions on what providers a patient may consult and virtually no restrictions on how physicians should practice their profession (I). The case study reveals how long it took to expand the initial legislation in 1928 and how powerful interest groups such as doctors and small business succeeded in constraining legislation and slowing its implementation. The Swiss health insurance system provides a model of what some market reform proposals in the U.S. might lead to in the best of all possible worlds! Since the Swiss system is federal, highly decentralized, and highly restrictive of government intervention, it is an important model for what many Americans cherish. The system of government subsidies to mutual funds and public hospitals results in almost universal coverage on a voluntary basis.
       Beyond the significant contributions of the book, there are three regrettable gaps. First, the curious reader cannot help but wonder what insights Immergut's institutional analysis would yield about other important health system models, e.g. Britain, Canada, Germany and Japan. Second, the case studies make no inferences about the likely course of health care reform in France, Switzerland and Sweden. This is a pity because all three countries are contending with different reform proposals. The French stalemate is reminiscent of the pre - 1958 period so well analyzed by Immergut. The rising costs in Switzerland are pushing the federal government to act but the obstacles remain enormous. And the Swedish demands for improving accountability to consumers appears to be leading to innovative forms of decentralized "public competition" (2). How will political institutions mediate the current process of health care reform? Unfortunately, Immergut is silent on this important question.
       Finally, it is regrettable that Health Politics pays so little attention to the evolution and politics of health care reform in the United States. In light of the failure of the Clinton plan or any other widereaching reform proposal - be it the single payer or managed competition strategy?how much is due to the design of our political institutions - Recent writings on American health politics have emphasized how the new politics has enabled important reforms through a kind of "technocratic corporatism" (3). But the past year of health care reform seems, in many respects, to have brought us back to the old politics of Medicare so well analyzed by Ted Marmor (4). The "disjointed incrementalism" of Charles Lindblom seems more relevant than ever in understanding contemporary health politics (5). For this reason alone, however brief her discussion of the United States, Ellen Immergut's comparative analysis of political institutions and their impact on health politics is essential reading for all those who wish to understand the limits and possibilities for health care reform here at home.
REFERENCES
  1. Fielding, J. and Lancry, J. "Lessons from France Wive la Difference'. The French Health Care System and US Health System Reform," JAMA 270 (1992): 748-56; Rodwin, V. and Sandier, S. "Health Care under French National Health Insurance," Health Affairs, Fall, 1993.
  2. Saltman, R. "Recent Health Policy Initiatives in Nordic Countries," Health Care Financing Review 13 (4, Summer 1992): 157-66.
  3. See, e.g., Brown, L. "Technocratic Corporatism and Administrative Reform in Medicare," JHPPL 10 (3), Fall 1995; Smith, D. Paying for Medicare. New York: Aldine de Gruyter, 1992.
  4. Marmor, T. The Politics of Medicare. New York: Aldine de Gruyter, 1970.
  5. Lindblom, C. "The Science of Muddling Through," Public Administrative Review, 19 (1959): 79-88.