Reform, change, and continuity in Finnish health care

This article describes some essential aspects of the Finnish political and governmental system and the evolution of the basic institutional elements of the health care system. We examine the developments that gave rise to a series of health care reforms and reform proposals in the late 1980s and early 1990s and relate them to changes in health care expenditure, structure, and performance. Finally, we discuss the relationship between policy changes, reforms, and health system changes and the strength of neo-institutional theory in explaining both continuity and change. Much of the change in Finnish health care can be explained by institutional path dependency. The tradition of strong but small local authorities and the lack of legitimate democratic regional authorities as well as the coexistence of a dominant Beveridge-style health system with a marginal Bismarckian element explain the specific path of Finnish health care reform. Public responsibility for health care has been decentralized to smaller local authorities (known as municipalities) more than in any other country. Even an exceptionally deep economic recession in the early 1990s did not lead to systems change; rather, the economic imperative was met by the traditional centralized policy pattern. Some of the developments of the 1990s are, however, difficult to explain by institutional theory. Thus, there is a need for testing alternative theories as well.     

States and the politics of incrementalism: health policy in Wisconsin during the 1990s

Wisconsin officials during the 1990s seemed poised to enact innovative and comprehensive health care reform. During that era, an ambitious, popular, and reform-minded governor led the state. The state had an unusually professional legislature. The state's economy was strong. Even with these advantages, however, the report card on the state's efforts is mixed. The state enacted a fairly modest set of reforms that were financed largely by the federal government and subject to extensive federal oversight. The Wisconsin story thus seems to be about the politics of incrementalism. But while critics of incrementalist politics point out that the number of uninsured continues to grow, the catalytic federalism witnessed in Wisconsin in the 1990s may well be the best model for implementing health care reform.     

The political management of managed care: explaining variations in state health maintenance organization regulations

In the 1990s, strong incentives for managed care organizations to control costs, once regarded as a fortuitous confluence of interests, came to be seen as antithetical to consumers' interests in quality of care. In response to this change in political climate, many states have greatly increased their regulatory control of managed care organizations since the mid-1990s. This activity is surprising in an era when public policy on health care issues is usually described as frozen, gridlocked, and/or stalemated as a result of intense activity on the part of organized interests. We take advantage of the variation in state regulations of health maintenance organizations (HMOs) to discover why some governments are able to address policy problems that are often perceived as intractable in a political if not in a true policy sense. From the history of HMOs, the backlash against managed care, and state responses to that backlash, we first extract a number of hypotheses about state regulatory activity. We then test these hypotheses with data on regulatory adoptions by states during the late 1990s and the early 2000s. Last, we discuss the findings with special attention to the role of politics in health care.     

Health care financing reforms in Germany: the case for rethinking the evolutionary approach to reforms

Health care reform has been a perpetual issue in German politics since reunification. Reform initially focused on restructuring the health care system of the former East Germany. It has subsequently focused on questioning whether the financing of the German social health insurance (SHI) system is sustainable, in light of economic malaise that characterized the 1990s and heightened global competition. In this article, we document twelve significant attempts to reform health care financing in Germany and critically appraise them according to the principles of solidarity and subsidiarity on which SHI systems were built. While the reforms in the aggregate offered the prospect of addressing the challenges faced by the system, the modest results of the reforms and remaining deficiencies of the system underscore the limitations of the evolutionary approach to reforms. This suggests that reformers should consider a more revolutionary approach.     

Between Immigration and Policing: Cross Recognition

Abstract: This article looks at the development of the UK's policies towards asylum‐seekers who are to be returned to some country other than the one where they fear persecution (its ‘safe third country’ policy). The Dublin Convention of 1990 addressed some of the problems which this policy created, but left others unresolved. Domestic legislation has progressively reduced the opportunities for challenging safe third‐country removals, especially to an EU state. The incorporation of the European Convention on Human Rights into UK law has generated new possibilities for challenging safe third‐country decisions where removal might damage physical or mental health. Articles 3 and 8 have been invoked in particular. The Dublin machinery established ‘rules’ to decide which member state was responsible for considering the asylum claim and the procedure to be followed. The article examines why the UK courts have said that these provisions are not justiciable in the English courts. Finally the article considers whether the experience with Dublin provides any useful guidance as to the approach that will be taken to European arrest warrants and extradition requests.     

A policy transformed by politics: the case of the 1973 Australian Community Health Program

During an era of health policy reform in Australia, community health advocates believed that community health centers (CHCs) could form a solid foundation for a new system of health care delivery. Instead, a proposal for national health insurance (Medibank) emerged as the predominant structural reform. Community health proposals were not abandoned, however, and a policy designed to give federal grant assistance for the establishment of CHCs was implemented in 1973. The historical account of how the 1973 Australian Community Health Program (CHP) was developed in the early 1970s is relevant to dilemmas faced by contemporary policy makers. Specifically, how did the CHP "survive" even though government leaders had moved away from traditional direct service models, choosing to focus more attention on indirect insurance reimbursement?     

Health policy in Denmark: leaving the decentralized welfare path?

In this article, we investigate developments in Danish health care policy. After a short presentation of its historical roots, we focus on the decades after the administrative reform of 1970, which shaped the current decentralized public health care system. Theories of path dependency and institutional inertia are used to explain the relative stability in the overall structure, and theories of policy process and reform are used to discuss gradual changes within the overall framework. Although comprehensive reforms have not taken place in Denmark, many gradual changes may pave the way for more radical changes in the future. The political climate currently seems to be more favorable toward structural reform than in the past.     

Regulatory Capitalism and the UK Labour Government's Reregulation of Commissioning in the English National Health Service

Today, policy analysts and regulatory governance scholars are sceptical about the capacity of the regulatory state hypothesis to describe change at the institutional level. For many, the hypothesis is a convenient oversimplification that fails to account for the hybridity of institutional arrangements within individual policy sectors and also for the divergence of reform trajectories across different national and sector‐based policy contexts. This article assesses the influence of the key themes of the regulatory state on the UK Labour government's reregulation of National Health Service (NHS) commissioning organizations. Following the critics, it argues that these themes are only partially evident in the programme. While the government has codified previously informal relationships with policies like Patient Choice and has also subjected commissioning organizations to metaregulatory techniques, its reforms have neither displaced public ownership and the direct supply of commissioning services with markets and new mechanisms for rule making and standard setting, nor have the reforms divided labour within the state by creating an independent agency to regulate NHS commissioning organizations via technocratic means. Under the reforms, NHS commissioning continues to take place within a structure of bureaucratic relationships. However, the article suggests that the hybridity of regulatory techniques at work within the UK Labour government's reregulation of NHS commissioning lends weight to the claim that the current era is one of regulatory capitalism. It concludes with a discussion of the consequences of this finding for the public policy and regulatory governance literatures.     

Who shall lead: is there a future for population health?

Despite renewed interest in population health concerns, elevation of this field in policy considerations faces many challenges. At present there is much concern about disparities and meeting improved population health objectives, but interest waxes and wanes with scientific developments and especially with dominant political alignments and ideologies. If the field of population health is to have sustained policy influence, it requires a persistent constituency, a strong organizational base both within and outside of government, and academic respectability. Population health faces many issues in seeking to become legitimized as both a unique field of study and as a significant force in public policy. Among these are a clear definition of the boundaries of the field, a continuing flow of resources for development, and attractive career structures for new recruits and future leaders.     

Majority Party Change and Committee Jurisdictions in State Legislatures

Committee jurisdictions are important in legislative organization, but the reorganization of jurisdictions has received scant attention, particularly in state legislatures, where the fluidity of committee organization allows us to examine rationales for change. In this article, I examine whether new majorities use jurisdiction reorganization for agenda‐control purposes. Examining 39 state legislatures between 2003 and 2012, I test whether committee patterns are less stable in legislative sessions under new majorities and the extent to which reorganization reflects party priorities. I find that new majority parties eliminate committees that reflect the other party's policy priorities and create committees that reflect their priorities.     

Regulatory Reform: Creating Gaps and Making Markets

This article argues that dispute processing reform, such as regulatory negotiation, plays a role in constructing a "crisis" in regulatory litigation and defining a new partnership between regulated interests and the state. Unlike traditional studies of regulatory reform, which tend to evaluate the behavioral impact of legal reform on policy, I argue that reforms themselves play a constitutive role in politics. The article examines the ideology of regulatory negotiation and presents empirical data on federal regulatory litigation in the U.S. Courts of Appeals (1940–1985), to demonstrate that this legal reform is part of a general drive toward a minimalist state.     

Legal Accountability in the Service-Based Welfare State: Lessons from Child Welfare Reform

Current trends intensify the longstanding problem of how the rule of law should be institutionalized in the welfare state. Welfare programs are being redesigned to increase their capacities to adapt to rapidly changing conditions and to tailor their responses to diverse clienteles. These developments challenge the understanding of legal accountability developed in the Warren Court era. This article reports on an emerging model of accountable administration that strives to reconcile programmatic flexibility with rule-of-law values. The model has been developed in the reform of state child protective services systems, but it has potentially broad application to public law. It also has novel implications for such basic rule-of-law issues as the choice between rules and standards, the relation of bureaucratic and judicial control, the proper scope of judicial intervention into dysfunctional public agencies, and the justiciability of "positive" (or social and economic) rights.     

The politics of universal access: the Massachusetts Health Security Act of 1988

This article analyzes the passage of an unprecedented state law, promising every resident access to affordable health insurance. The Massachusetts Health Security Act of 1988 was the product of a set of political and financial pressures that had been developing for nearly a decade. Hospital, insurance, and business interests were unable to reach a new accommodation on hospital payment. This logjam created the opportunity for a policy breakthrough, but did not inherently lend itself to progressive reform. It was consumer activism that forced the traditional powers in health policy to address the interests of the uninsured. By imposing a more public-interest agenda on the process, consumers were able to change the configuration of the stalemate, but could not resolve it. The particular terms of the stalemate, however, made possible a new, more aggressive role for state government in health policy. Unable to satisfy their competing interests within a policy framework that had universal access as a goal, traditionally powerful interest groups found themselves increasingly dependent on the state to broker a new agreement. While the many concessions made to these groups are likely to prove to be the bill's undoing, the unraveling of the agreement will not end the story. The same pressures which led to passage of the Massachusetts law and which are now causing other states to act will continue to exert their effect until a more durable solution is found.     

When Do Challengers Succeed? Nongovernmental Actors,Administrative Agencies,and Legal Change: Shifting Rules for Oregon's Private Forests

Regulatory regimes are notoriously resistant to change, so when less powerful actors manage to reshape long‐established rules and gain increased access to a natural resource the interesting question is why? This article investigates relations between different claimant groups and the state in the reshaping of the regulations governing Oregon's private forestlands, how this process was mediated by broader political opportunities and constraints, and the conditions that supported a shift in the legal regime that benefited less advantaged interests. The intent is to deepen our understanding of the circumstances under which well‐established rules of governance are altered. Analysis points to each of the following variables as significant for successful reform: (1) active challengers and their success in reframing issues to support their goals, (2) new political opportunities facilitating wider participation in the rulemaking process, and (3) concurrence between local and national aspirations supporting reform. While each condition is noteworthy, it is insufficient on its own. Rather, my study comparing two contested administrative rules suggests that a clear alignment of all three variables provides the strongest impetus for legislative and administrative rule changes at the state level benefiting less advantaged interests.     

Breaking gridlock: the determinants of health policy change in Congress

Prior to the 2010 health care reforms, scholars often commented that health policy making in Congress was mired in political gridlock, that reforms were far more likely to fail than to succeed, and that the path forward was unclear. In light of recent events, new narratives are being advanced. In formulating these assessments, scholars of health politics tend to analyze individual major reform proposals to determine why they succeeded or failed and what lessons could be drawn for the future. Taking a different approach, we examine all health policies proposed in the U.S. House of Representatives between 1973 and 2002. We analyze these bills' fates and the effectiveness of their sponsors in guiding these proposals through Congress. Setting these proposed policies against a baseline of policy advancements in other areas, we demonstrate that health policy making has indeed been far more gridlocked than policy making in most other areas. We then isolate some of the causes of this gridlock, as well as some of the conditions that have helped to bring about health policy change.     

Nondecision making and inertia in Portuguese health policy

Despite there having been a positive context for initiating health care reforms in Portugal in the past fifteen years (accompanied by political consensus on the nature of the structural problems within the health care system), there has been a lack of reform initiatives. We use a process-based framework to show how institutional arrangements have influenced Portuguese health care reform. Evidence is presented to demonstrate inertia and nondecision making in three critical areas of Portuguese health policy: clarifying the public-private mix in coverage and provision, creating financial incentives and motivation for human resources, and introducing changes in the pharmaceutical market. Several factors seem to explain these processes, namely, problems in the balance of power within the political system, which have contributed to a lack of proper policy discussion; a lack of pluralism in the formation of health care policies (with low participation from citizens and high mobilization among structural interest groups); and the low priority of health care in public sector reforms. Portuguese politicians should be aware of the pitfalls of the current political system that constrain participatory arrangements and pluralism in policy making. In order to pursue health care reform, future governments will need to counterbalance the strong influence of structural interest groups.     

The Emergence of Penal Extremism in California: A Dynamic View of Institutional Structures and Political Processes

This article examines legal and political developments in California in the 1970s and early 1980s that led to extreme changes in the state's use of imprisonment. It uses historical research methods to illustrate how institutional and political processes interacted in dynamic ways that continuously unsettled and reshaped the crime policy field. It examines crime policy developments before and after the passage of the state's determinate sentencing law to highlight the law's long‐term political implications and to illustrate how it benefited interest groups pushing for harsher punishment. It emphasizes the role executives played in shaping these changes, and how the law's significance was as much political as legal because it transformed the institutional logics that structured criminal lawmaking. These changes, long sought by the law enforcement lobby, facilitated crime's politicization and ushered in a new era of frenetic and punitive changes in criminal law and punishment. This new context benefited politicians who supported extreme responses to crime and exposed the crime policy process to heightened degrees of popular scrutiny. The result was a political obsession with crime that eschewed moderation and prioritized prison expansion above all else.     

Judicial Reform and Rationalization: The Diffusion of Court Reform Policies Among the American States

Explaining the diffusion of judicial reform policies among the American states is an elusive task. Are such policies simply part of the larger policy process revealed in the comparative state policy literature? Or b court reform a policy arena unto itself, responding to factors uniquely legal or professional in nature? Our inquiry begins with Max Weber's sociology of law from which we adopt his concept of rationalization as a schema of policy development. According to Weber, the “rationalization” of legal institutions would accompany the advancement of capitalism in modernizing nations. Thus, we might expect specific judicial reform policies expressly aimed at rationalizing the structure and process of state court systems to be closely associated with each other and with commonly accepted indicators of economic development among the states. As part of our investigation, we relate court reforms to broader policy innovations among the states, drawing on earlier “diffusion of innovations” research. Our data indicate a strong connection between judicial reform and more general patterns of innovation diffusion among the states, but provide only modest support for Weber's assertions about the rationalization of legal systems under advancing capitalism. Three of the selected reforms cluster together and are largely explainable by indicators of economic development. Two other reforms do not fit this pattern, and their “behavior” requires additional discussion and research. Thus, the diffusion of judicial reform policy is partly accounted for by factors found in explanations of general policy innovations across states, but other, as yet unidentified, factors apparently influence certain aspects of judicial reform. The connection between Max Weber's legal sociology and policy development among the American states might at first blush seem remote or tenuous. However, this article attempts to use Weber's insights into modern legal systems to (1) examine a specific area of state policy making–judicial reform–and (2) establish a connection between policy development in the court reform area and the larger literature on general policy innovation in the American states. This inquiry is inspired by the lack of theoretical integration apparent in the literature on court reform, on the one hand, and the absence of empirical analyses connecting court reform data with “diffusion of innovation” policy studies, on the other.