Diverging Patterns of Health Care Commodification in Central and Eastern Europe

The demise of communism forced Central and Eastern European countries (CEECs) to fundamentally reform their ‘premature’ welfare states, including healthcare (Kornai 1997), following the blueprints from the mature welfare states in Western Europe (Hacker 2009; Rechel/McKee 2009). One of the disturbing outcomes of the reforms is a very high level of unmet health needs in the region, by far exceeding the respective figures in most welfare states in Western Europe. Indeed, in a number of CEECs up to one third of respondents declare unmet health needs, the highest levels in the European Union; at the same time, in a couple of CEECs unmet health needs are at the lowest levels in Europe (Kaminska/Wulfgramm forthcoming). This suggests divergence within the region despite common communist past and seemingly similar post-communist policy designs. Even more disturbing, an important share of unmet health needs in CEECs is cost-related, which implies a commodification of health services (Flood/Gross, 2014; Reibling, 2010) whereby access to healthcare occurs on the basis of the ability to pay or market position, rather than need (see Esping-Andersen 1985). This in turn suggests inability or unwillingness of the organized power in those emerging welfare states to modify and counterbalance (through politics and administration) the play of market forces in the individually experienced ‘social contingency’ of sickness (Briggs 1961). This contribution explores the reasons behind, on the one hand, the divergence in these outcomes between CEECs and the established welfare states in Western Europe, and on the other hand, the ‘within difference’ across the CEECs. It follows the power resources approach (Korpi 1978, 1983, 2006, Esping-Andersen 1985, 1990; Ebbinghaus 2015) which attributes welfare state policy designs and outcomes to the distribution of power resources in society between major interest groups, the nature and levels of power mobilization, structuration of labour movements and patterns of political coalition-formation. This approach is particularly useful for analyzing welfare state development in CEECs where the post-1989 ‘capitalism without compromise’ (Bohle/Greskovits 2006) has curbed the organized labour’s capacity to shape public policy or to win material benefits (Crowley/Ost 2001). At the same time, post-communist ‘varieties of capitalism’ -- distinct from Western European models -- have emerged in CEECs (Bohle/Greskovits 2012) and the trade unions, although incomparably weaker than their Western European counterparts, differ across the region as to capacities and results (Kaminska/Kahancova 2017). Empirically, the first part of the paper analyzes patterns of healthcare commodification in Central and Eastern Europe by studying the level and distribution of unmet health needs across CEECs. Micro-data from EU-SILC on unmet health needs and individual characteristics offer the opportunity to show a comprehensive picture of these patterns. Second, these individual responses are merged with macro-data (from Eurostat, WHO, ICTWSS and CPDS) for a larger country sample in order to identify determinants of healthcare commodification. The dataset allows for analysing observations from 28 European countries in the period 2005-2015, with our main variables of interest being indicators of the distribution of power resources.