Public Health Systems in The Age of Financialization - Ana Carolina Cordilha

"In Public Health Systems in the Age of Financialization, Ana Carolina Cordilha unpacks policy shifts that have transformed public health systems into vehicles for financial speculation and capital accumulation. While it is commonly thought that these systems are being cut back in the period of financialization, the author shows that current changes in public health financing go far beyond budget cuts and privatization measures. She examines how public health systems are adopting financial instruments and participating in financial accumulation strategies, with harmful impacts on transparency, democratic accountability, and health service provision. With an in-depth study of both the French and Brazilian systems, Cordilha explores the different ways in which this process unfolds in central and peripheral countries"-- Provided by publisher PART 1 Financialization as a New Concept to Examine Public Health Systems Change 1 Financialization and Its Inroads into Public Policy 19 1 Finance and Its Workings 19 1.1 Conventional Views of Finance 21 1.2 The Heterodox Critique 23 1.3 The Academic Scholarship on Financialization 27 2 Together but Different: Financialization in Central and Peripheral Countries 32 2.1 Financialization in France 35 2.2 Financialization in Brazil 41 3 Financialization and Social Provision 48 3.1 The Inroads of Finance in Areas of Social Provision 48 3.2 The Financialization of Social Policy 50 3.3 The Financialization of the State 54 3.3.1 Financialization and Central Governments: Changes in Public Debt Management 60 3.3.2 Emerging Themes on State Financialization: Local Governments, Public Investments, and Social Provision 64 2 Public Health Systems in Times of Financialization 68 1 Public Health Systems (pHS) 69 1.1 Reasons for State Intervention in Health Care 69 1.2 Defining Public Systems 71 1.3 Common Institutional Arrangements of PhS 72 1.4 PhS in Historical Perspective 76 2 Conventional Approaches to Assess Health Systems Change 83 2.1 Deconstructing the Notion of Privatization 86 vi 2.1.1 Agents 87 2.1.2 Narratives 89 2.1.3 Theoretical Underpinnings 89 2.1.4 Impacts 90 3 Financialization in the Health Sector 91 3.1 The State of the Art of the Health Financialization Literature 93 ConTEnTS 3.1.1 Investment Platforms: a New Approach to Finance Global Health Policies 94 3.1.2 Ownership Restructuring: Reshaping the Landscape of Private Health 95 3.1.3 Financial Innovations: a Novel Strategy for Public and Non-profit Agencies 97 3.2 Gaps in the Existing Research for the Public Sector 98 3.3 Financialization as a Distinctive Type of PhS Change 103 3.3.1 Agents 104 3.3.2 Narratives 107 3.3.3 Theoretical Underpinnings 107 3.3.4 Different Paths, Same Driving Force: Austerity Policies 108 3.3.5 Impacts of Financialization 109 3.3.6 Bridging Concepts Together: Privatization as a Driver of Financialization 110 3.3.7 Financialization as a Driver of Privatization 111 PART 2 From Theory to Practice: How Financialization Reshapes Public Health Systems 3 The French System Pioneering Financialized Strategies in PHS 121 1 Social Security and Public Health Care in France 121 1.1 The French System of Social Security 122 1.2 The French Public Health System: Assurance Maladie 124 1.3 The Trajectory toward Universalization 127 1.4 The Path of Neoliberal Reforms in Assurance Maladie 128 1.5 Assurance Maladie’s Accounts in Perspective 131 2 Mechanisms of Financialization 136 2.1 Financialized Strategies for Long-Term Debt Management: the Social Debt Amortization Fund 137 ConTEnTS 2.1.1 Contextualizing cADES’ Creation 137 2.1.2 Deconstructing cADES’ Strategy 139 vii 2.1.3 cADES in Numbers 141 2.1.4 Instruments and Costs 145 2.1.5 Investors and Intermediaries 150 2.1.6 State Support 151 2.2 Financialized Strategies for Short-Term Financing by the Central Agency of Social Security 152 2.2.1 Contextualizing the Adoption of Financialized Practices by the Central Agency 152 2.2.2 Acoss’ Financing Strategy in Numbers 156 2.2.3 Instruments and Costs 156 2.2.4 Investors and Intermediaries 162 2.2.5 State Support 163 2.3 Government Policies toward Hospitals: Credit-Based Investment Programs 164 2.3.1 The French Hospital Sector at a Glance 164 2.3.2 Bringing Hospitals and Banks Closer Together: a New Approach to Finance Investments 165 2.3.3 Delving into the Credit-Based Financing Strategy 168 2.3.4 The Role of the State 172 2.4 Addendum: Public Hospitals Venturing into Financial Markets 173 2.4.1 Financing Conditions and Intermediaries 174 3 Taking Stock 175 4 The Brazilian System A Trajectory (Mis)led by Financialization 176 1 Social Security and Public Health Care in Brazil 177 1.1 The Brazilian Social Security System 177 1.2 The Brazilian Public Health System: Sistema Único de Saúde 181 1.3 The Quest to Consolidate Universal Health Care: Successes and Drawbacks 186 1.4 The Public Health System Today 189 1.5 SUS Accounts in Perspective 190 2 Mechanisms of Financialization 196 2.1 Public Health Revenues Feeding Financial Accumulation: Policies at the Federal Level 197 viii ConTEnTS 2.1.1 The 1999 Monetary Policy Regime and Its Associated Fiscal Policy Framework 198 2.1.2 Reinforcing the Macroeconomic Regime: Health Spending Rules 202 2.1.3 Backing the Macroeconomic Regime: Rules for Social Security Revenues 204 2.1.4 Data Analysis and Interpretation: Health and Financial Expenditures in Perspective 206 2.1.5 The Role of Financial Institutions 215 2.2 Investing SUS Revenues in Short-Term Financial Assets: Policies at the Subnational Level 217 2.2.1 The Role of Health Funds 218 2.2.2 The Rio de Janeiro State Health Fund 224 2.2.3 The Federal District Health Fund 227 2.2.4 When the Financial System Overrides the Health System: Revenue Retention Practices 230 2.3 Subsidized Credit Lines for SUS Providers 235 2.3.1 SUS and the Philanthropic Health Sector 236 2.3.2 Government Programs Connecting Philanthropic Hospitals and Banks 240 2.3.3 Consigned Credit for Philanthropic Health Establishments 241 2.3.4 The Bank-Based Strategy in Numbers 245 2.3.5 How Credit-Based Hospital Financing Serves the Financial Sector 248 3 Taking Stock 250 5 Uncovering the Hidden Costs of Financialized Public Health Insights from Case Studies 253 1 Systematizing Results: Common Trends 254 2 Shared Trends, Unique Expressions: Contrasting Central and Peripheral Experiences 256 3 A Broader View of Financialized Policies in pHS and the Role of the State 259 4 Impacts of Financialized Policies on the Foundational Principles of pHS 262 Appendix Additional Information on Data Sources and Treatment 269 References 272 Index 313