The Health Care Reform-Social Movement
Health care reform is a process that builds upon the current health insurance system in the United States. It’s intended to provide more people with coverage, establishing consumer protection and setting up a system to shop for insurance. I have spent most of my time for this assignment researching social movements and what struck me most was current health care reforms. I am not quite sure if this qualifies fully as a social movement but it seemed so to me. After much reading and research I came to the conclusion that health care reform is a reformative social movement in which President Obama has bulldozed through the first and second stages of initial unrest and agitation of the American people and the resource mobilization that has spent much time and money putting this reform together and mobilizing mass media propaganda influencing and “educating Americans as to why this reform must happen. Stage three’s organization was a debacle at best in which the deadline to enroll was fast approaching but the enrollment process itself was quite difficult to maneuver. This stage has pushed us into the fourth stage of institutionalization where the movement has entered into bureaucracy. At this point the excitement has definitely faded a bit and people like myself who were previously uninsured are feeling a bit of relief in addition to resentment. I don’t particularly see an organizational decline but as stage five states, it seems to be becoming reinvigorated in the sense that people are seeing the benefits of Obama Care as well as those who are still defying and fighting it. I find it to be a reformative social movement because the reform pertains to only a portion of society, in this case the uninsured. President Obama is changing the ways of health care and the ability to obtain it.
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As the health care reform sits teetering between institutionalization and organizational decline, there are many issues being argued and fought against.The Health Care Reform-Social Movement
Explanations for the expansion of the welfare state have frequently centered on the importance of left-wing political parties and labor unions. Scholars have even pointed to the rare but growing significance of social democracy in the industrializing world. Yet, in the field of healthcare, labor unions frequently oppose sweeping universalistic reforms that threaten to erode members’ existing benefits, and those most in need of healthcare in rural areas and the informal sector are often the least organized politically. In the absence of mass demands, who then is responsible for universal healthcare programs in the industrializing world, and by what means do they successfully advocate for far-reaching reforms? This article explores the role that “professional movements” played in expanding access to healthcare in an industrializing nation that was engaged in processes of democratization. Mass movements are typically composed of lay people; by contrast, professional movements are made up of elites from esteemed professions who command knowledge, networks, and access to state resources that set them apart from ordinary citizens. The account illustrates how and why professional movements are able to play such a powerful role in health policymaking in the industrializing world, points to the need for more research on professional movements in other cases and policy domains, and discusses their relevance to social change in the industrializing world.
Thailand’s landmark 2002 universal healthcare law upended the assumptions of development practitioners and scholars alike by demonstrating that a resource-constrained country in the Global South could fashion a surprisingly sweeping social contract with its citizens. Under the “30 baht to cure all diseases” program, for just 30 baht (75 U.S. cents), Thai citizens could now go to a clinic or hospital near their home, see a doctor, and receive a diagnosis, referrals, treatment, and medication. For the poor, even the fee of 30 baht was waived. The program consolidated two existing state health insurance programs for low- and middle-income people and expanded coverage to the 30% of the population who had lacked it.
In providing access to comprehensive care, Thailand’s Universal Coverage reform represented a major break from the Alma-Ata-era Primary Health Care movement, which stressed prevention, community participation, and self-care, as well as more recent, if less visible, efforts in the late 1990s by the World Health Organization to promote “new universalism,” which emphasized only essential, cost-effective care (Chorev 2012:178–89). Thailand’s program was, by contrast, a more comprehensive experiment that included access to high-cost curative services and a wide array of medication (Pitayarangsit 2010:83, 109). Although some high-cost services were initially excluded, over time the program’s benefit package came to include dialysis, cancer drugs, treatment for AIDS, and medication for psychiatric illnesses. Adoption of the policy in Thailand preceded the flurry of Universal Coverage-related activity which went on at the international level in the years that would follow.The Health Care Reform-Social Movement
Thailand’s program succeeded in correcting long-standing historical disparities in mortality between the rich and poor by opening hospital doors to millions (Sen 2015). And healthcare analysts lauded it as a model for the industrializing world (Damrongplasit and Melnick 2009; WHO 2010).
If the policy’s sweep came as a shock to many, the highly constrained political and economic context in which it came into being made the policy’s adoption even more surprising. In 2001, Thailand’s economy was just four years removed from the Asian financial crisis, which had led its currency to collapse, and a USD 17 billion structural-adjustment package from the IMF, which had put a straitjacket on government spending. The communist party was banned, and the late 1990s had seen the arrest of one health minister on corruption charges, with government ministries more generally—and the health sector in particular—known to be rife with clientelism and corruption (Chuengsatiansup 2003; Doner and Ramsay 2004).
Even more striking was that Thailand’s movement for health reform was not driven by those most in need. Labor unions focused on the needs of workers in the formal sector, who had already won important health rights through the country’s social security program and were more concerned with protecting them. And political parties were not known for producing coherent programmatic platforms tied to ideology. More often, political battles were pitched on the basis of personalities, with patronage and pork-barrel politics the norm (Selway 2011). How then to explain Thailand’s remarkable achievement?
While left-wing political parties and labor movements (Stephens 1979; Korpi 1983) and direct citizen participation (Sen 1999; Fung and Wright 2003; Baiocchi 2005; Evans and Heller 2015) have received a great deal of attention in helping explain the expansion of important new social rights, I argue that the reform’s success is hard to understand without examining the strategic actions of a movement of progressive medical doctors (the country’s most esteemed profession) that operated from within Thailand’s Ministry of Public Health and autonomous para-statal organizations affiliated with it.The Health Care Reform-Social Movement
Operating from these privileged positions in the state, members of this “professional movement” of physicians pushed policy outcomes by helping bring a new constitution into existence, which fundamentally altered the political context in profound ways; by embedding the policy in an innovative new political party’s campaign platform; by convening a high-level panel on universal healthcare that heightened visibility on the issue during the election season; by financing and mobilizing a grass-roots petition campaign to force parliament to consider legislation; by implementing the policy as a national pilot project before it became law to outmaneuver a medical profession that was increasingly hostile to the program and to prevent politicians from backtracking on campaign promises; and by drawing on support from international allies to resist retrenchment efforts.
A political party open to putting universal health care on its agenda was ultimately necessary for the policy to become law, but the role Thailand’s Rural Doctors’ movement played in the institutionalization of the policy constitutes a necessary but insufficient aspect of the story that hasn’t been fully appreciated. Without the strategic actions of this professional movement, there is scant evidence that the policy would ever have gotten on the political agenda in the 2001 election, much less been adopted as policy or implemented. Healthcare access was simply not a major concern of mass movements at the time. Politicians had historically resisted taking it up, and political parties’ own polls even suggested that it was not a leading issue for voters. The wide-ranging influence of Thailand’s professional movement on the agenda-setting, policy formulation and adoption, and implementation phases of the policy process suggests the need for research on similar movements in other countries to see whether they play similarly interesting roles.The Health Care Reform-Social Movement
Scholars have acknowledged that the critical actors in health reforms “tend not to be presidents or political parties, but rather experts embedded in national bureaucracies” (Ewig 2010:63; see also Kaufman and Nelson 2004; Weyland 2007; Haggard and Kaufman 2008:197; Chorev 2012; Dargent 2014). But just who these influential actors are, and why and how the state plays such an important role in their work, have been under-theorized. This article advances the concept of “professional movements” to help fill this lacuna.
Professional movements are a category of collective action that occupies an in-between space among the broader categories of the professions and social movements, referring to social movements that operate within and sometimes against broader professions. Professional movements can be profitably juxtaposed with more traditional mass movements that are grass-roots by nature and largely composed of and led by lay people. By contrast, professional movements are movements of elites from esteemed professions. While some members of professional movements might gain their training and skills informally through processes of “expertification,” rather than through credentials bestowed on them by universities (Epstein 1996), most receive their training through formal processes. Members of professional movements share defining characteristics of social movements—common purposes, solidarity, and sustained forms of collective action (Tarrow 1994). Like members of traditional social movements, members of professional movements have activist pedigrees, but it is the knowledge, networks, and resources they command that set them apart from ordinary citizens. Whereas traditional social movements often lack the stable sources of money, organization, and state access that political parties and interest groups have (4), the elite professional identities of actors in these movements give them access to resources that sustain professional movements and make them formidable political actors.
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This concept has its origins in earlier work (Broadhead and Facchinetti 1985), although the scholars who coined the term only did so in passing and never actually defined it. More recent work (van Gunten 2015) has resurrected the term but largely failed to distinguish it from rival concepts. In relating professional movements to the institution of important new social policies, the work presented here attempts to demonstrate the relevance of this form of collective action to broader issues of politics, policy, and power beyond simply the preservation of professional autonomy, authority, and jurisdictional boundaries.The Health Care Reform-Social Movement
Professional movements can be distinguished from concepts such as scientific and intellectual movements, which involve “collective efforts to pursue research programs or projects for thought in the face of resistance from others in the scientific or intellectual community” (Frickell and Gross 2005:206; my italics). Professional movements are also different from “identity movements within professions,” which seek to critique a profession’s existing orthodoxy and promote cultural change by reshaping institutional logics and redefining role identities (Rao, Monin, and Durand 2003). While the strategies and actions of professional movements may alter the institutional logics of a profession, cultural change within the profession is not their primary objective. Rather, they seek to advance broader policy changes that will affect the broader society by stepping outside their professional jurisdictions and using a variety of strategic tools.
Professional movements are also distinct from “issue networks,” which are composed of large numbers of participants with variable degrees of commitment, ranging from individuals to powerful interest groups, all of whom move freely and fluidly in and out of the network (Heclo 1978:275–76). While knowledge of the issues is central to both professional movements and issue networks, membership in professional movements tends to be smaller, more sustained over time, and more exclusive, with membership coalescing around professional identities that at the same time have their roots in social-movement activism. Professional movements can also be contrasted with epistemic communities of scientists and experts who share causal and principled beliefs and play important roles in setting policy agendas and defining state interests. But whereas epistemic communities, “if confronted with anomalies that undermined their causal beliefs, would withdraw from the policy debate” (Haas 1992:18), the value-driven members of professional movements believe that a commitment to science, while important, does not come at the expense of commitment to cause. As is often the case with members of grass-roots social movements—and transnational advocacy networks (Keck and Sikkink 1998)—shared normative beliefs, rooted in concerns about human rights and social justice, are at the heart of their motivation.
Research has found that the size of social movements is positively associated with their influence on stages of the policy process, like agenda-setting (Johnson 2008); but professional movements challenge this understanding. Even though they tend to be small (at least relative to grass-roots social movements), they exert influence not just in the agenda-setting phase of the policy process, but also in policy formulation, adoption, and implementation, and in holding the government accountable for the policy once it is in place. In this way, their involvement in policymaking goes well beyond the kind of lobbying associated with interest groups.
In exploring the role and impact of professional movements in an important industrializing country that began the process of democratization in 1992, this research responds to recent calls for researchers to look for “specific forms of organization and strategies that are more productive in some political contexts than in others” (Amenta et al. 2010:296). Whereas conventional wisdom has pointed to how democratization empowers the masses, the evidence presented here points to an underappreciated dynamic: that democratization sometimes empowers progressive elites, who can in turn have a powerful impact on politics.
While this is not the only type of professional movement, the case I examine explores the actions of a professional movement composed of activist physicians, who advocated for major health reforms in opposition to the broader medical profession of which they were a part. The case illustrates how a well-positioned professional movement was particularly well disposed to take advantage of political opportunities that arose after the country’s democratic transition.The Health Care Reform-Social Movement
Foundational research on the medical profession in Thailand shows that doctors have almost exclusively come from (moneyed) urban classes (Maxwell 1975:483). And survey evidence suggests that Thais hold more esteem for doctors than for any other profession (Ockey 2004), with patients frequently revering them as “gods” for their power to heal (Wongsamuth 2016). Relative to ordinary citizens, they are elites.
However, status hierarchies also exist within professions. While some members of Thailand’s professional movement enjoyed high status within the profession prior to their advocacy for reform (as evidenced by their election to the board of the profession’s regulating authority, the Medical Council), most were not specialists and did not hold positions at prestigious university hospitals where knowledge was being produced, or at wealthy private hospitals that served the needs of international medical tourists. Rather, they began their careers as activist general practitioners at hospitals in Thailand’s poorest rural areas.
Apart from the esteem accorded them as public servants in the Ministry of Public Health, these elites occupied a status on the periphery of the broader profession, and their advocacy for universal healthcare ultimately led to their marginalization within it. Following the reform, they were purged from the ranks of the Medical Council—replaced by reform opponents—and some members of the professional movement described themselves as “outcasts.” So a related puzzle this work addresses is how a relatively marginal subdivision of the medical profession managed to obtain the power and resources to overcome the interests of the broader profession.
Beyond Expert Knowledge as an Explanation for Professional Advantage in Policymaking
While other work has drawn attention to the importance of expert knowledge in explaining physician and scientist influence in advocacy related to complex issues like health policy, this research has devoted considerably less attention to the resources and networks that enable professional movements to overcome overwhelming and entrenched opposition.The Health Care Reform-Social Movement
Expert knowledge makes professionals legitimate and credible players in policy conversations. It can also serve as the basis for strategic interventions in the policymaking process that advance professionals’ goals, for example when experts convene a high-level panel to focus attention on a certain policy issue, or when they advise political leaders on technically complex issues. However, I argue that it is state resources and social networks that provide them with unlikely advantages over conservative international organizations and powerful professional associations.
The privileged role granted to scientists and technical experts in complex policy matters, including health policy, has long been acknowledged (Haas 1992; Walt 1994; Brint 1996). Yet, technical knowledge alone does not explain how groups of professionals can and sometimes do play influential roles in policymaking that go beyond setting policy agendas and defining state interests. After all, in the domain of health policy, technical knowledge is also available in great abundance to members of the medical profession more broadly, and important work in sociology and political science has demonstrated the power that entrenched professional associations can wield in maintaining the status quo (Freidson 1970; Larson 1977; Starr 1982; Abbott 1988; Skocpol 1997; Quadagno 2004, 2005; Hacker 1998, 2002). To account for change amid such constraints, I argue, we need to know more about the unique resources and networks that professionals can bring to bear on the policymaking process.
Haas (1992) provides some guidance related to the precise kinds of resources that offer professionals unique advantages. He argues that much of professional influence and ability is a function of “the extent to which an epistemic community consolidates bureaucratic power within national administrations and international secretariats” (30). This is important because “it is the political infiltration of an epistemic community into governing institutions which lays the groundwork for a broader acceptance of the community’s beliefs and ideas about the proper construction of social reality” (27).The Health Care Reform-Social Movement
In its most concrete form, access to the state provides professionals with extraordinary means to influence policy. In some cases, holding privileged positions in the state gives professional movements unique advantages over entrenched interest groups generally thought to hold considerably more power. In Thailand, for example, this enabled doctors in the professional movement to reverse the normal order of the policymaking process—implementing the healthcare reform as a national pilot project before the policy had even been passed into law (Harris 2015). The constituencies that were built by virtue of citizens’ experience with the program subsequently made policy adoption in parliament a foregone conclusion—and a particularly powerful example of policy lock-in (Pierson 1993).
However, state office is not the only leverage that professional movements can bring to bear in policy battles. While professional associations typically act alone in representing the interests of the broader profession they represent, professional movements at times draw on networks to mobilize allies to support their cause. Other important work (Carpenter 2001) has pointed to how bureaucrats sometimes bring together diverse coalitions of supporters to insulate agencies from political control and make ignoring agency initiatives costly. Likewise, professional movements seek to ensure their voices are heard by partnering with allies who can bring evidence of voter support, financial assistance, and legitimacy to reform efforts. For professional movements in the industrializing world, this has meant forging alliances with academics, non-governmental organizations, political parties, and international organizations.The Health Care Reform-Social Movement
