Why health policy in the coming election is a thing of mystery not mastery

In a year of anxiety and unfamiliarity, we are about to undergo a familiar, and perhaps reassuring, political ritual on 17 October.

The wheels of our electoral democracy appear to be running smoothly when compared with countries such asthe US. We will have an electoral contest, and there is little doubt the result will be accepted by whoever loses.

We have to go...back to electoral contests of the 1990s to find examples of strong differences between party platforms

That is reason enough to value our electoral process, but readers of this newspaper might also be hoping the election is valuable for its substance.

But do elections actually make a difference to what happens in health policy? This is not a straightforward question to answer.

With mixed member proportional representation, governments are formed by coalitions of parties, and this means no party can guarantee before an election that its preferred policy directions will be supported by prospective coalition partners.

Given this inherent uncertainty, should we put much weight on policy platforms?

You might be reassured by the fact that, after the 2017 election, the primary care policy platform of one of the major parties was implemented faithfully.

The idea that became reality – Community Services Card eligibility for lower general practice fees – was the same as that proposed by the National Party (that did not win government), not Labour’s more generous offer. Go figure!

More importantly, our votes will affect the direction of health policy only if there are substantive differences between competing parties.

Of the two major parties, only National had released its 2020 health policy platform at the time of writing. In broad terms, it is difficult to distinguish National’s platform from what Labour has done so far, and what it has indicated it might do.

Some clear demarcation around the recommendations of the Health and Disability System Review Panel may emerge.

However, I suspect few voters will vote according to whether they think the number of DHBs needs to be reduced or not.

And National hasn’t indicated it will be the knight in shining armour to save PHOs from the slow death envisaged by the review.

We have to go quite some way back to electoral contests of the 1990s to find examples of strong differences between party platforms.

But these elections took place after National had radically restructured the health system, and this restructuring was, famously, not flagged in its 1990 election platform.

All this raises a wider question: how much does it matter which parties are in government? Again, the best New Zealand examples of changes of government that brought on significant change are all from last century (1984, 1990, 1999).

Each led to health system restructures, but perhaps only in 1999 were those changes flagged in election campaigns.

Since 2000, there has been either broad consensus or little substantive difference between the major parties on health services policy.

Fix elective surgery waitlists, tick.

Don’t mess with the structure of the system again, tick.

Try to fix mental health services, tick.

What about smaller parties?

Apart from the moderating effect New Zealand First had on National’s marketisation of the health system after the 1996 election, it’s difficult to find examples of how smaller parties’ policies have shaped what happens subsequently.

A decade ago, a colleague and I investigated how much the ideological complexion of political parties shaped the direction of health policy in 11 countries, including New Zealand, between 2003 and 2010. The answer, in a nutshell, was not much.

Centre-left governments were somewhat more likely to pursue population health objectives. However, for other broad, comparable policy directions such as
access, equity, quality and efficiency, there was no discernible difference between what happened under centre-left or centre-right governments.

Political scientists who study parties and voting behaviour distinguish between the “ideological” (appealing to the distinct values of core party voters) and “vote maximisation’” (seeking to attract swinging voters) underpinnings of policy positions.

Again, research across a wide range of high-income countries covering 40 years, shows overwhelmingly that vote maximisation eats ideology for lunch.

This is not surprising when the proportion of voters that would prefer more, or much more, spending on health is consistently between 70 per cent and 80 per
cent, according to New Zealand Election Surveys.

However, when it comes to what actually happens, funding appears to be one major divide between Labour and National-led governments.

Under National, per-capita government spending on health flatlined from 2010 to 2017, after nearly a decade of higher-than-inflation increases under Labour.

The burning question is whether this was attributable to differences between parties or to the global financial crisis.

COVID-19 will further confound comparisons of spending over the next few years.

Elections are but one thread of a much larger tapestry of health policy change. Often the meaning and significance of a particular election becomes apparent only in retrospect. Scribes in 2040 may well look upon the 2020 election as a watershed for health policy in New Zealand.

But for those of us stuck in the present, we have little idea of exactly how it matters.

Tim Tenbensel is associate professor, health policy, in the School of Population Health at the University of Auckland