Federalism,Physicians, and Public Policy: A Comparison of Health Care Reform in Canada and Brazil

Abstract

This article uses comparative historical analysis to explore physicians’ involvement in health care reform in Canada and Brazil. Drawing on historical institutionalism, the analysis stresses how, beyond partisanship, physicians build consensus around and promote specific policy ideas, and how federal institutions shape physicians’ mobilization. In both countries, physicians’ mobilization shaped the emergence of universal health care coverage, but in quite different ways, because of the differing federal institutions. Although the Brazilian medical lobby was far more heterogeneous than the Canadian profession, one faction was able to mobilize at the local level to pursue policy ideas favorable to universal health coverage.     

Beyond the categories: human service managers view the new federal aid

Social agency chief executives in six program areas--welfare, health, mental health, community action, model cities, and community mental health centers--were surveyed to determine their reaction to the recent revenue sharing/block grant efforts to decentralize the federal aid system. Despite their strong belief that social initiatives and values were advanced principally by federal action, and that excessive reliance on state and local officials could severely jeopardize social programs with weak constituencies, agency executives also recognized major weaknesses in traditional categorical grant policy and, to varying degrees, supported revenue sharing and block grant alternatives. Those agencies largely dependent on federal support for their survival--model cities, community action programs, and community mental health centers--tended to support the new aid efforts only reluctantly. Those agencies more fully integrated into the regular policy-making arrangements of local government--health, welfare, and mental health agencies--were considerably more positive in their endorsement of greater decentralization.     

The influence of federalism on fiscal policy making

Abstract. This article attempts to refine the statement that federal states face difficulties in fiscal policy making because of the territorial division of powers by comparing two federal countries, Canada and Germany. These two countries differ in terms of their type of federalism: Canada displaying a power-separation system and Germany corresponding to a power-sharing type. According to the authors, the territorial factor influences fiscal policy making through the distribution of taxing and spending powers as well as through patterns of intergovernmental relations. The use of fiscal policy instruments and the likely effects on conflict and cooperation in those two countries is discussed with empirical evidence. The authors come to the conclusion that federalism is indeed a constraint on fiscal policy making, but that the two types of power division face different obstacles and deal differently with fiscal problems. In the power-separation system of Canada, the federal government has encompassing competencies to use fiscal policy instruments unilaterally and without restraint, but faces a lack of concerted action with the provinces which reduces its scope of action in fiscal policy making. In the power-sharing system in Germany, concerted action facilitates macroeconomic stabilisation strategies but the compulsory negotiation system distorts the use of fiscal policy instruments by distributive bargaining.     

Drivers of Policy Instrument Selection for Environmental Management by Local Governments

Local governments commonly pursue environmental objectives that exceed state and federal minimum requirements. Although research informs our understanding of factors that lead cities to adopt such policy goals, the underlying mechanisms employed to achieve them are not well understood. This article examines factors that drive the choice of policy instruments that cities use to pursue local environmental objectives. The literature links the structure of the local governing body, characteristics of the community and target populations, and the nature of the policy problem to instrument selection. Building on this, the authors model the dynamics shaping cities' use of regulations, financial incentives, or combination thereof, to pursue a variety of different environmental objectives. Results indicate that community racial composition and political leaning influence instrument choice when policy targets the public at large. Alternatively, when policy targets particular stakeholder groups, such as developers, the characteristics of the local governing body are of greater importance.     

Money and Mandates: The Politics of Intergovernmental Conflict

The federal government's relationship with the states dependsin part on the level of federal aid and the number of federalmandates. Environmental policy, with less federal aid and moremandates, differs from education policy and health policy. Thevolume of intergovernmental litigation is heavier and rhetoricalreferences to intergovernmental partnerships by agency headsare more common in environmental policy. Waivers are more commonin education policy and health policy, but that appears to bea function of congressional policies largely barring environmentalpolicy waivers. Federal judges are more supportive of the federalgovernment's position on environmental protection and educationthan its position on health care. Overall, federal funding andmandates appear to have an impact on state governments, federalbureaucrats, and federal judges.     

Federalism and suitable housing for the frail elderly: A comparison of policies in Canada and the United States

Abstract

The frail elderly have special multidimensional housing needs beyond affordability, including shelter that is more adaptive to reduced function and offers supportive services. Suitable housing for this population comprises three policy areas—housing, health care, and social services. In a federal system, development and implementation of policies in these areas involves participation of several levels of government and the nongovernmental sector. This paper uses federalism as a conceptual framework to examine and compare these policy areas in Canada and the United States.

In both countries, general national housing policies—relying heavily on the nongovernmental sector and characterized by joint federal‐provincial programs in Canada and by important local government roles and age‐specific programs in the United States‐have benefited the elderly. The effects of such policies on the frail elderly, however, have been less positive because of the general lack of essential human services and, to a lesser degree, health care that enables them to live outside institutions. This is especially true in the United States, where health care policy is fragmented and is dominated by a private insurance system, partial federal financing of health insurance for the elderly, and tense federal‐state relations in financing health care for the poor. Although Canadian policies and programs operate autonomously and more uniformly within a national health plan, neither country has a universal, comprehensive long‐term care system. Geographically diverse patterns of social services, funded by grants to states and provinces and the nonprofit sector, are common to both countries. However, the United States has inadequately funded age‐specific programs and has relied on a growing commercial service provision. Housing outcomes for frail elders are moving in the right direction in both countries; however, Canada seems to be better positioned, largely because of its health care system. As increased decentralization continues to characterize the three policy areas that affect suitable housing for frail elders, the United States can learn from Canada's negotiated federalism approach to more uniform solutions to merging housing and long‐term care.     

State-Federal Diffusion and Policy Learning: From Enterprise Zones to Empowerment Zones

There is little empirical evidence on whether the federal governmentlearns from policy experimentation in the states, the "laboratoriesof democracy. " Interviews with participants involved in formulatingthe federal Empowerment Zones/Enterprise Communities programoffer evidence of limited policy learning from state enterprisezones. Respondents were aware of general trends and drew a fewgeneral conclusions, rather than borrowing from any particularstate. None of the federal policymakers conducted an activesearch for information about the state zones, but state andfederal organizations served as channels of information aboutthe state programs. This finding suggests that such organizationsassist state-federal diffusion as well as interstate diffusionof policy ideas.     

The Evolution of Low‐Income Housing Policy, 1949 to 1999

Abstract

The evolution of low‐income housing policy during the past 50 years can be divided roughly into two segments: the first running from 1949 to the 1973 Nixon moratorium on subsidized production programs and the second from 1973 to the present, marked by a diminished federal leadership role and an increased state and local role. After tracing the rise of the federal leadership role represented in the Housing Acts of 1949 and 1968, this article focuses on the development of three important policy instruments that mark the devolution of housing policy: housing vouchers, housing block grants, and the Low‐Income Housing Tax Credit.

The three‐pronged strategy of vouchers, block grants, and tax credits has achieved reasonably good results and attracted an unusual degree of political consensus. A steady expansion of all three offers the most promising path to the “realization as soon as feasible” of the national housing goal.     

Once more into surplus: Reforming expenditure management in Australia and Canada

Canadian and Australian federal government budgets have returned to surplus. Over the past two decades both countries have undertaken financial management and budgetary reforms in an effort to control expenditure growth and public debt. They exchanged ideas, borrowed techniques, and shared reform experiences. Yet during the mid-1980s and early 1990s they displayed markedly different levels of success in expenditure control. This article explains why relatively similar instruments of expenditure control and financial management produced different outcomes in Australia and Canada. The analysis suggests that budgetary techniques will have marginal impact unless they are congruent with broader policy management systems and administrative cultures. The comparative analysis provides important lessons for budget reformers in all jurisdictions.     

Uneven local implementation of federal policy after disaster: Policy conflict and goal ambiguity

As climate change continues to increase both the frequency and intensity of environmental hazards and disasters, the need for a cohesive national mitigation policy grows. As the environmental federalism scholarship indicates, the inherent tension in federal, state, and local policy implementation highlights that despite a national need, environmental quality is a local public good. To complicate matters, there is disagreement about the optimal level of decision-making regarding the adoption and implementation of environmental policy. This study addresses this gap by considering the role of policy ambiguity and conflict in policy implementation. The analysis relies on primary qualitative data collected from open-ended interviews with 22 local government officials in 12 municipalities following Hurricane Harvey. Through the lens of policy ambiguity and conflict, we find confirmatory support for the idea that policies with less ambiguous goals are more likely to be implemented. Furthermore, we find that policy conflict arises when local governments perceive there is little for the community to gain by implementing the federal program. Thus, the level of protection afforded to citizens varies greatly between communities and is influenced heavily by politics. This research supports the Ambiguity-Conflict Model of policy implementation, an oft-cited but rarely tested theoretical framework for assessing the intergovernmental politics of policy implementation. It also demonstrates the barriers to local implementation of federal environmental policy in a nested system of government.     

Mental health and substance abuse insurance parity for federal employees: How did health plans respond?

A fundamental concern with competitive health insurance markets is that they will not supply efficient levels of coverage for treatment of costly, chronic, and predictable illnesses, such as mental illness. Since the inception of employer-based health insurance, coverage for mental health services has been offered on a more limited basis than coverage for general medical services. While mental health advocates view insurance limits as evidence of discrimination, adverse selection and moral hazard can also explain these differences in coverage. The intent of parity regulation is to equalize private insurance coverage for mental and physical illness (an equity concern) and to eliminate wasteful forms of competition due to adverse selection (an efficiency concern). In 2001, a presidential directive requiring comprehensive parity was implemented in the Federal Employees Health Benefits (FEHB) Program. In this study, we examine how health plans responded to the parity directive. Results show that in comparison with a set of unaffected health plans, federal employee plans were significantly more likely to augment managed care through contracts with managed behavioral health "carve-out" firms after parity. This finding helps to explain the absence of an effect of the FEHB Program directive on total spending, and is relevant to the policy debate in Congress over federal parity.     

EMPLOYMENT AND TRAINING POLICY AND AMERICAN IDEAS: OLD PROBLEMS AND EMERGING PROGRAMS

The federal government has, relative to other areas of social welfare program activity, been especially slow in the development of employment and training policy. The reasons for this can be found in terms of an understanding of the most basic American political and economic ideas. The history of federal initiatives in employment and training policy is traced briefly and the impact of certain American political ideas on this pattern of development is analyzed. Particular attention is given to the issues of coordinating of employment and training programs and the increased role of the state and private sector in designing and managing such programs. It is suggested that in light of certain historic American political patterns, there might be costs to moving in commonly sought after ways that are not readily evident.     

State Renewable Energy Governance: Policy Instruments,Markets, or Citizens

Since the 1990s, state governments in the United States have diversified policy instruments to encourage the electric power industry to deploy renewable sources for electricity generation. This study identifies the trends and variations in renewable energy (RE) policy governance among states and examines the effectiveness of policy instruments in the deployment of RE sources for electricity production. This study explores 18 state legislative, RE‐related regulations, programs, or financial incentives existing between 2001 and 2010 in 48 states in the United States. Renewable energy policies were classified into three types of policy approaches: command‐and‐control, market‐based, and information instruments. Results suggest that authoritative approaches are more likely to be effective in the governmental intervention toward a pre‐existing market, and information instruments and citizen participation became important in the power industry in the 2000s. In addition, it gives us some evidence that federal assistance under the American Recovery and Reinvestment Act of 2009 influenced the overall growth of the renewable electricity industry, in addition to state government–led policy designs.     

Territorial Representation and the Opinion–Policy Linkage: Evidence from the European Union

A key feature of federal systems is the representation of subnational units by “territorial representatives” in policymaking at the federal level. How do such arrangements influence the linkage between public opinion and policy outputs? I argue that policymaking under territorial representation should be systematically skewed toward opinion in those states where citizens care about a policy issue and have a uniform view on it. This claim is tested using a novel data set of policy change in the European Union (EU), covering 211 policy issues and 6,506 observations of opinion–policy dyads. Results show that measures weighting opinion across member states by how much national citizens care about an issue are better predictors of policy change than EU‐wide mean opinion. Moreover, congruence between state‐level opinion and EU‐level policy becomes more likely, the more salient and clear‐cut opinion in a member state is. These findings refine our understanding of the opinion–policy linkage under territorial representation.     

Not Centralisation but Decentralised Integration through Australia's National Mental Health Policy

This article challenges dominant perceptions of Commonwealth centralisation in Australia's federal system. While recognising the Commonwealth has entered a range of policy fields not anticipated by federal founders, it argues this does not equate to a generalised unidirectional and hierarchical orchestration of state/territory functions. The crucial case of mental health policy is presented as an alternative scenario in Australia's federal experience. Theoretically key challenges from the multi‐level governance literature are proffered against the centralisation thesis. These include queries about the origins of Commonwealth directives and assumptions of zero‐sum notions of state/territory autonomy. Brief empirical analysis highlights the role of the Commonwealth as a conduit of horizontal and vertical flows of knowledge through the national mental health policy agenda. Given disconnect and diversity between national ambitions and their realisation at state/territory level, it is argued better proceduralisation through bottom‐up peer dialogue and feedback present alternative routes towards decentralised integration.     

The National Interest and the Federal Role in Education

The current discussion of national goals for education createsa predicament for the federal government. Political pressureis mounting for an increased federal role in education, butits ability to play this role is limited both by its own budgetand policy constraints and by the increase in education policyinitiatives of state and local government over the past tenyears. This predicament is not amenable to solution by resortto traditional doctrinal or functional views of federalism.It requires the formulation of a new federal strategy. Amongthe initiatives the federal government might take are raisingpublic discourse about educational performance, sponsoring collaborativeefforts to reduce the incoherence of current educational reformsat the high school level, and increased use of federal categoricalprograms as development projects for new approaches to teachingand learning. These initiatives have the advantage of beingconsistent with current federal budget and policy constraints,drawing upon traditional federal functions, and complementingstate and local reform efforts.     

Mandates and Management Challenges in the Trenches: An Intergovernmental Perspective on Homeland Security

Scholars and practitioners agree that homeland security policy implementation is contingent on a strong system of intergovernmental relations. The responsibilities associated with the homeland security mission, often mandated, cut across federal, state, and local boundaries. Local-level stakeholders are especially important players in the implementation process. This article presents a local perspective on the way intergovernmental relations have changed—and the reasons for those changes—since 9/11. Results of a survey of county and city officials in Florida provide evidence that intergovernmental cooperation has improved as a result of federal and state mandates. These results are refined by an analysis of the effects of specific local characteristics and the quality and quantity of vertical and horizontal networks on intergovernmental cooperation and local preparedness. Homeland security appears to be a policy area in which mandated cooperation and coordination—in a time and place of urgency—have actually strengthened the intergovernmental system.     

Disasters,Catastrophes, and Policy Failure in the Homeland Security Era1

The September 11 attacks triggered federal policy changes designed to influence emergency management in the United States, even though these attacks did not suggest a need for a wholesale restructuring of federal policy in emergency management. Instead, for several reasons, federal policy's emphasis on terrorism and emergency management significantly degraded the nation's ability to address natural disasters. The federal government sought to create a top‐down, command and control model of emergency management that never fully accounted for, positively or normatively, the way local emergency management works in practice. The Obama administration will have to address the questions raised by the reorganization of federal emergency management responsibilities. While the context in which these changes have occurred is unique to the U.S. federal system, there are interesting implications for emergency management in nonfederal systems.     

Likely effects of devolution on the redistributive character of policy agendas

This article assesses two competing views of the effects federal devolution may have on the future of health, education and welfare programs in the United States. One school of thought argues that devolution of social policy to the state and local level will have negative consequences for the less affluent. A contrasting view maintains that devolution will spur innovations at the state and local level, which in turn will lead to more effective and efficient social programs. Dileo analyzes presidential and gubernatorial speeches over a period of 5 years to assess the state of U.S. social policy. He concludes that the federal government is generally more supportive of redistributive policies than are the states.     

Deterring discrimination with data

Discrimination on grounds of race, sex, and handicap persists in many local school districts in spite of nearly twenty years of sustained attention from federal policymakers. Because litigation proceeds slowly and expensively, and because administrative attacks on discrimination have been stymied by political controversy, additional policy strategies merit careful consideration. We studied the operation of one such strategy in nine local districts: the mandatory collection of data concerning civil rights matters in schools. Data collection and reporting shaped local compliance with civil rights laws in four ways: by threatening local officials with future penalties, by providing political ammunition to constituencies that care about civil rights, by allowing local districts to learn about their own performance, and by framing school practices in ways that heighten awareness about equity. In this policy setting, data collection has advantages and disadvantages that complement those of other enforcement strategies. In this and other policy settings, data collection has power to elicit compliance even in the absence of conventional enforcement.This paper is based on research supported by the National Institute of Education, Grants NIE-G-81-0037, NIE-G-81-0038, and NIE-G-83-0008. We acknowledge with gratitude the research assistance of Rosa Yvonne Herrera, Elizabeth Greenberg, and Lauren Rothfarb, and the encouragement of Grace Mastalli.