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Book Review: Chiara Saraceno (ed.) Families, Ageing and Social Policy: Intergenerational Solidarity in European Welfare States, Edward Elgar: Cheltenham/Northampton, MA, 2008; ix+320 pp.: 9781847206480, £75 (hbk)

Europe is argued to be built upon its welfare states. Among the different pillars of European welfare states, the health system is arguably the most influential one in creating social cohesion and sense of belonging. However, the mechanisms that motivate reform, its politics and the nature of integration of European health systems are largely underresearched. This book attempts to tackle this by providing the first complete analysis of European health politics that considers both theoretical and empirical developments. The first and crucial contribution the book contains is that of bridging the gap that heterogeneous institutions and denominations raise in studying European health systems. Indeed, so much is an effective accident of history in the organization of European’s welfare systems that, as Greer argues, even useful categories such as ‘social insurance’ or ‘national health system’ fail to shed light in such a complex policy responsibility such as health care. ‘Secret garden’ is the term that Greer uses to define the traditional health policy of member states, namely a protected welfare responsibility crafted by local politics and surrounded by barriers to entry. However, the influence of the European Union (EU) has been more subtle here than in other areas, as its influence perhaps operated through informally changing values and operating procedures rather than through formal institutions and instruments. The EU brings about new forms of political and social interaction among member states, along with stimulating change around a core set of issues including patient mobility, competition and choice. Altogether, Greer argues that the EU is transforming the ‘garden’ into a ‘park’. The influence of the European Court of Justice might not lead to health system convergence as some might expect. In part, this is the result of countries’ resistance, through lobbying, to further integration. This lobbying, Greer shows, seems to reproduce existing local lobbying and accommodate inherited structures to the exigencies of EU health policy. Countries exhibit incremental change which, step by step, challenges health policy autonomy unless defended through lobbying. EU influence on health policy stands as an example of the traditional neo-functional paradigm, where regulatory spillovers from other sectors impact on health. In Greer’s terms ‘health is a perfect case of European integration – negative, deregulating integration – driven by the EU institutions without democratic legitimacy or an obvious justification’. Scott Greer has done a remarkable job in explaining how the Europeanization of health policy takes place, how institutional legacies exert an influence in lobbying, how harmonization exhacerbates path-dependent welfare structures that in turn impede a ‘race to the bottom’, and why the idea of a European social model creates positive external effects, even if it is a only an ad hoc policy construction. This endeavour is carried out empirically through the presentation of detailed case studies from four different countries, along with an extended presentation of the state of the art in the literature. Unlike other studies, this book manages to provide a rather complete vision of the influence of the EU in a rather specialized area such as health policy where the EU influence is driven by regulatory spillover and informal interactions among networks of lobbyists. Greer recognizes that the construction of European health policy makes use of instruments that both formally and informally influence political action. The rise of health care lobbying is a clear-cut demonstration that the EU exerts an influence in health policy not only through regulaton, but mainly by means of network creation. He argues that efficient lobbying takes place through a careful mangement of relevant information, coordinated action of aligned interests and agents being nimble and active in pursuing their goals. However, not all member states are equally efficient, which as Scott argues might give rise to a ‘northwestern bias’ in health policy making, calling for either a reform in how lobbying works and/or for more transparent mechanisms for health policy interests to be representated in Europe. The project that this book manages to set out encompasses a huge and intense research effort that includes substantial fieldwork. It is essential reading for those trying to undertand what is happening to health policy in Europe.