Inching toward Incrementalism: Federalism, Devolution, and Health Policy in the United States and the United Kingdom

Abstract

In the United States, the recently enacted Patient Protection and Affordable Care Act of 2010 envisions a significant increase in federal oversight over the nation's health care system. At the same time, however, the legislation requires the states to play key roles in every aspect of the reform agenda (such as expanding Medicaid programs, creating insurance exchanges, and working with providers on delivery system reforms). The complicated intergovernmental partnerships that govern the nation's fragmented and decentralized system are likely to continue, albeit with greater federal oversight and control. But what about intergovernmental relations in the United Kingdom? What impact did the formal devolution of power in 1999 to Scotland, Wales, and Northern Ireland have on health policy in those nations, and in the United Kingdom more generally? Has devolution begun a political process in which health policy in the United Kingdom will, over time, become increasingly decentralized and fragmented, or will this "state of unions" retain its long-standing reputation as perhaps the most centralized of the European nations? In this article, we explore the federalist and intergovernmental implications of recent reforms in the United States and the United Kingdom, and we put forward the argument that political fragmentation (long-standing in the United States and just emerging in the United Kingdom) produces new intergovernmental partnerships that, in turn, produce incremental growth in overall government involvement in the health care arena. This is the impact of what can be called catalytic federalism.

Policy venue preference and relative trust in government in federal systems

“…Health policy authority is split between the state and federal levels in the United States in numerous ways (Gold, Mittler, Aizer, Lyons, & Schoen, 2001; Sparer, France, & Clinton, 2011). The federal government plays a large role in three of the most salient health policies—Medicare, Medicaid, and the 2010 Affordable Care Act (ACA), which expanded not just public—but federal—efforts to link Americans to insurance (Jacobs, 2014).…”

Healthcare Systems in Comparative Perspective: Classification, Convergence, Institutions, Inequalities, and Five Missed Turns

“…In the US, federalism organizes the healthcare system – some functions are performed by the central government, other functions are performed by local units, and others are a blend (Greer & Jacobson 2010). Sparer et al (2011) argue that the 2010 Affordable Care Act in the United States, which devolves substantial responsibility for healthcare insurance (already fragmented by state-specific Medicare and Medicaid policies) to the US states, could follow the same path as devolution in the UK in 1999, which has sparked intergovernmental efforts at strengthening government involvement in the healthcare system. We also note that the Affordable Care Act, which marks a real change in the US healthcare system, expressly excludes undocumented immigrants, potentially reinforcing a citizenship-based axis of inequality.…”

Beyond Path Dependence: Explaining Healthcare Reform and Its Consequences

“…Lastly, the federalist approach to healthcare can also have striking unintended consequences. Sparer, France, and Clinton (2011) have argued that the fragmented nature of the U.S. healthcare system has created incremental growth in government involvement that they refer to as catalytic federalism . Joint programs and efforts create incentives for multiple levels of government to become involved in policy decisions.…”