Read an Excerpt
Doctors and the State
The Politics of Health Care in France and the United States
By David Wilsford Duke University Press
Copyright © 1991 Duke University Press
All rights reserved.
ISBN: 978-0-8223-7865-5
CHAPTER 1
Introduction: Comparing Organized Medicine and Health Policies in France and the United States
A physician, put to sleep in 1900 by a magic spell, awakens in 1930. The countryside and the cities are transformed. Empires have fallen. But medicine has changed little. Like 30 years before, the physician treats weak hearts, calms stubborn coughs, softens expectorations, but he almost never changes the outcome of illnesses which if benign, heal alone, and if serious, almost always kill. A second physician, drowsing off in 1930, is roused from his lethargy in 1960. He recognizes absolutely nothing: acute meningitis, tubercular meningitis, acute tuberculosis, general infections, malignant endocarditis, bronchial pneumonia all can be cured. Addison's disease can be treated, pernicious anemia is no longer pernicious, surgeons open hearts and brains, hemotologists save newborn babies by replacing their blood, psychiatrists become chemists and correct serious disorders of the spirit. Sound waves, lamps, rays and microscopes probe the organs, the tissues, the cells, and even molecules (Bernard, 1966).
Physicians once were harassed practitioners of dubious medicine. Then with great improvements in science and technology and in their own organizing, physicians became prestigious dispensers of health. It was the end of the nineteenth century. Physicians' successes were so impressive that gradually everyone claimed a right to them. Through governments and labor unions, the sick obtained more and more access to health care. However, more access meant more money paid to physicians and their helpers for the goods and services required to operate the industry of health. Subsequently, governments, labor unions, and employers started to question the financial commitment that had grown up around them—and which continued to grow. So physicians came under attack. Some physicians were better than others at resisting attack, at least for a time, and some attacks were more effective than others.
This book seeks to understand why this has been so by focusing on the relations between organized medicine—important providers of health care—and the public and private payers of that health care. The book compares this relationship between physicians and payers in France and the United States. I will concentrate on the contemporary, postwar period, especially the 1970s and 1980s, although the earlier history of medicine's organization and the growth of health is certainly important to the story that I will tell here.
The two countries are suited for comparison because they provide a useful contrast of approximate extreme types along two dimensions: First, France's system quickly evolved into what Roemer (1977) classifies as a public insurance system (cf. Wilsford, 1988; Galant, 1955). The American system, however, has remained more or less resolutely free enterprise in spirit, and largely (though less and less) in fact. These differences are manifested in the distribution of public and private sources of financing health care in the two countries: In 1982, 74.8 percent of the financing of the French health care system was public; 25.2 percent was private. In the United States, only 43 percent of financing was public; 57 percent was private (cf. Heidenheimer et al., 1990:62).
Second, France and the United States exemplify strong versus weak state traditions in the health care sector. The French state tradition of Colbert and Rousseau, in which the state uniquely embodies and protects the general interest, has constituted one important underpinning of state autonomy in health. This contrasts with the American tradition of the "stateless" state wherein the free play of political forces is thought to result in the common good. In the United States, state autonomy in making health policy has been weak as many health interests, especially physicians, have exploited many political openings into the state to their advantage. Yet both France and the United States are advanced industrial democracies which have experienced similar economic expansion and recession in the postwar period.
Equally important, each country also permits free and abundant medical association activity. Physician organizations are numerous and active in the organization of health care delivery systems and in the politics that affect their health care system interests. Moreover, in both countries the medical profession succeeded in using the rise of science and technology at the close of the nineteenth century to establish hegemony over legitimate health care delivery. Most striking, orthodox medicine succeeded in both countries at defining what constituted legitimate.
But the political success of organized medicine in the postwar period has varied. The first argument this book makes is about this difference. In general, French physicians have seen a decline in their political power starting in the 1950s and continuing to the present. American physicians, by contrast, enjoyed almost unvarying (and hard-won) political success until the rise of competition from corporate medicine and the intervention of private employers and insurers in health care decisionmaking from roughly 1975 to the present. Even so, today American physicians continue to be more politically successful than their French counterparts.
Economic pressures on all welfare states have induced states and private insurers to act upon the prerogatives of traditionally favored interest groups such as physicians. The French state, with its "strong" state structures, has been able to shape health care politics more effectively than the "weak" American state. The differences in the distribution of authority and in the tactical advantages available to the French and American states explains what professional associations have chosen to do politically and their effectiveness—and it explains some of the varying success of the two states in controlling health care expenditures. Although officials in both countries consider health care costs a grave problem, there are significant differences in their respective health care expenditures. In 1987, health care expenditures in France totaled 8.6 percent of GDP compared to 11.2 percent of GDP in the United States (CREDES, Eco-Santé, 1989).
We will see subsequently, however, that the lack of strong state responses in the United States has been filled partially by private insurers and employers. This points to the second argument this book makes, that of universalism between the two cases. In fact, the study shows, the traditional and hard-fought claims of professionalism based upon scientific expertise—claims advanced everywhere by organized medicine—and the social prestige and economic rewards that have resulted from these claims have eroded in the face of the "fiscal imperative" in health care. This imperative has driven the financiers of care, governments, private insurers, and employers, to relentlessly try to curb the traditional prerogatives of health care providers, especially physicians. In chapter 10 I will lay out a more systematic test of this second argument by subjecting the findings which emerge from the French-American comparison to initial evidence drawn from Britain, Canada, Japan, and West Germany. Each of these countries is a large, advanced industrial democracy that is characterized by a sophisticated, complex health care system. A common locus of policymaking everywhere is the confrontation of scarce resources to pay for health care with a rising demand for and technical capacity to provide the care. Each health system is characterized by a highly organized medical profession with distinct perceptions of its interests and the desire to press its claims regarding health policy upon the political system. But all these countries are also characterized by the increasing inability—or more accurately, unwillingness—to pay for so much expensive care. Hence, difficult choices face public policymakers and private managers in each system about how to organize and how to pay for the extensive delivery of high-quality health care. Such choices never fail to affect deeply the way physicians practice medicine, as well as the social and economic rewards that they may or may not enjoy by practicing their profession.
The book, therefore, makes a complex, dual argument. On the first hand, what are the conditions that underlay a significant difference cross-nationally in the influence of organized medicine in the shaping of health policy and the organization of the health system? On the second hand, are there universal forces leading to an erosion of organized medicine's influence over time in every country?
In particular, this second argument challenges an earlier view that dominated our understanding of physician influence on health policy for some time. Marmor and Thomas (1970), for example, argued that whenever there was a dispute about methods of provider payment, physicians always won. There was strong evidence in support of this view and others like it. But in twenty years scholars of comparative health policy must reverse themselves.
In the struggle to finance increasingly expensive health care systems, public officials and private insurers—as well as coalitions of contributors, especially employers—have striven mightily to curb the autonomy of health providers, especially physicians. Physicians are a common target because their crucial gatekeeping position in health care delivery makes them an easily identifiable linchpin of the system. Governments and insurers everywhere pursue reforms that restructure and redesign the supply side of the health care system. These reforms eventually curb clinical autonomy and contain physicians' income in every advanced, industrial democracy. Well-organized groups of providers (physicians) may delay reforms in some countries, depending on the character of the political system. They will do so in part by advancing claims of expertise. But in no country will physicians avoid these reforms forever because the huge costs underlying the fiscal imperative in health care will eventually override even the most aggressive professional arguments.
This argument points to one fundamental similarity between the conclusions I draw today and those of health policy scholars of a generation ago. Both then and now, the evidence at hand suggests that it is the character of the policy domain that drives politics over the long term rather than the reverse. That is, there is a universal logic in health care that drives policies toward the same goals across countries and across cultures. This holds in spite of the fact that over the short term there is clearly broad variation across countries and cultures in the timing of policy, in the nature of policy instruments, and in the distribution of health care responsibilities.
DATA AND METHODS
The bulk of this study falls between the single-country treatment of a traditional case study and a wider comparative effort. Restricting the comparison to two countries should provide deeper insight into decisionmaking and negotiating processes within the state and the medical profession than would be possible with a more aggregated approach. But explicitly comparing two countries, rather than concentrating on only one, should also permit an evaluation of the activities of medical associations and bureaucratic and political actors against a better comparative backdrop than would be possible with a single-country study. The cross-national approach enables a more careful weighing of the determinants of policy than a single-country study would permit and a distinguishing between the culturally specific and the more general factors that affect political behavior and policy outcomes.
This study focuses on the political: that is, the shaping of what is possible between and among diverse, often conflicting interests. The methods used here are therefore less quantitative and more qualitative than may be typical of similar studies. Quantitative studies, of course, are essential to the demonstration of aggregate relationships, but they contribute less to contextual knowledge. Also, health care studies in particular often confine their focus to evaluations of the equity or efficiency of health care systems. But the politics which constrains or provides opportunities for system formation and reform, as well as the pursuit of professional and consumer interests within the system, often fall outside the capabilities of quantification.
To appreciate the importance of the contextual variables which structure health care politics, I will address systemic, historical, and cultural factors across the two countries. This approach is complementary to both single-nation case studies and aggregate analyses. First, contextual variables—such as the "strong" versus "weak" state traditions or the character of shifting alliances between interests—are less tangible and difficult to evaluate quantitatively. Second, this approach should shed light on alternative ways of organizing policymaking in health care that are not necessarily considered within a single cultural-political system. Evans (1986:25) stated this point best: "Nations do not borrow other nations' institutions.... The point is that by examining others' experience you can extend your range of perceptions of what is possible."
For two years in France (1984–86), I conducted interviews with about forty-five people. The length of each interview varied from about one to two-and-a-half hours. I interviewed medical association activists and highly placed functionaries in ministries dealing with health care matters. Medical association activists made up a little over two-thirds of the total. In addition, a lengthy questionnaire was administered to 255 presidents and general secretaries at the departmental level of the Confédération des Syndicats Médicaux Français (CSMF), the principal medical association of private practitioners. The questionnaire comprised ten pages of detailed closed and open questions. Eighty-four responded. Fifteen national delegates of the Syndicat Autonome des Enseignants de Médecine also participated by answering the questionnaire. Their answers to the open-ended questions are used as a source of qualitative data on the thinking of medical professors and hospital physicians.
Many of the questions of this survey were suggested by similar ones in the survey undertaken by Suleiman in his seminal study of French administration (1974). In general, almost all respondents to the questionnaire completed not only the closed questions but also gave detailed answers to the open questions. I have used this as a source of qualitative data in addition to the quantifiable data from the closed questions.
Finally, various archival sources were mined for contemporary and historical information. In France I was permitted unlimited access to the files of the Quotidien du Médecin and of the Panorama du Médecin, the two principal periodicals which report on matters of medical, political, and social interest to French physicians. The files of the Quotidien du Médecin extend back to 1970, those of the Panorama du Médecin to 1974. I was also permitted unlimited access to the archives of the Concours Medical (perhaps the closest French equivalent to the American New England Journal of Medicine). Its numbers date from 1879. This source in particular provides invaluable information on the historical roots of French medical syndicalism which we will explore in chapter 4.
For the analysis of American health care politics, I have relied on interviews with and information from about fifteen employers and health care professionals—mainly from areas of California, Texas, and South Carolina—as well as interviews with group and government officials in Washington, D.C. Especially for the American case, I have used the rich secondary literature extensively. I have also interviewed officials in Japan, West Germany, Canada, and Britain for the fiscal imperative argument in chapter 10, as well as having consulted the secondary literature.
Many individuals in each of these countries have contributed confidential information to this study, either through their answers to questions in interviews or through providing me with internal documents. Throughout this study I have treated their contributions anonymously.
PHYSICIANS' STRATEGIC POLITICAL AND MARKET POSITIONS
The first constant shared by France and the United States is that their respective medical professions were able to consolidate important political and market positions at the turn of the century. This historical power would later make some countervailing force essential to controlling health care expenditures.
For most of the nineteenth century, physicians in both Europe and the United States enjoyed neither high incomes nor high status. Their market position was poor, thus they did not occupy a strategic political position and their political influence was consequently minimal. One reason for this was that medical technology was primitive and physicians were generally no more successful at treating illness and disease than witches, traveling medicine men, faith healers, and the like (cf. Rothstein, 1972; Starr, 1982; Bungener, 1984). Further, patients did not seek out physicians if they could not pay them. Medical incomes were consequently low. Although the objective demand for health care was higher than in the twentieth century (given sanitation conditions, for example), there was little subjective demand for health care.
(Continues...)
Excerpted from Doctors and the State by David Wilsford. Copyright © 1991 Duke University Press. Excerpted by permission of Duke University Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
