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Dr. Guergana Stolarov-Demuth


Lansstraße 5-9
14195 Berlin

Systemic Pressures, Dynamic Coalitions and Contested Legislative Rules. Health Insurance Reforms in Switzerland, the United States and the Netherlands

Dissertation in Politik

Mentoring Team:
First supervisor: Prof. Christian Lammert
Second supervisor: Prof. Ellen Immergut
Third supervisor: Prof. Lora Anne Viola

The dissertation investigates the dynamics of major legislative reform in political systems in which the power to legislate is strongly fragmented among multiple actors and institutions. In particular, the dissertation focuses on the introduction of national health insurance (NHI) in Western Europe and North America. In order to ensure universal coverage NHI systems are redistributive and impose strong state regulation on insurers and physicians. Therefore various interest groups tend to oppose NHI. While in some pioneer countries NHI was introduced already in the late 19th−early 20th century, in countries in which the legislative power is strongly fragmented (such as Switzerland, the United States, and the Netherlands) powerful interest groups successfully used the particularities of the legislative system to block multiple attempts to pass NHI-legislation. This left many people uninsured or covered under weakly regulated private health insurance. Eventually, some form of NHI was passed in Switzerland in 1996, in the Netherlands in 2005, and in the United States in 2010. Thus, the question emerged: how could we explain the success of those major reforms given the previous resistance and the difficulty to assemble a legislative majority for a NHI in a fragmented legislative system?

Aiming to answer this question, the dissertation is designed as a comparative study including six cases. For each one of the three countries the comparison focuses on one failed and one successful reform attempt to introduce NHI chosen according to a “most similar” research design from the period 1970−2010. Based on this comparative analysis, the dissertation is emphasizing the role of two properties of voluntary and weakly regulated private health insurance systems: their tendency to overspend and the insurers’ considerable leeway in defining the access conditions to health insurance. Notably, this leeway allows the insurers to deny access to health insurance or charge higher prices based on an individual’s risk profile. In all of the three countries included in this study, the persistent trend of continuously rising health care costs, to which voluntary private health insurance systems are particularly prone, put a heavier cost burden on particular groups and intensified the competition among insurers, making insurers’ discriminatory practices even more prevalent. As a result, over a longer period of time the distributive dynamic of the private health insurance changed dramatically. This negatively affected crucial interest- and electoral groups (e.g. the elderly and the middle class), and increased the willingness of the insurance companies and the center-right parties to join a NHI-coalition. In addition, aiming to facilitate the building of a NHI-majority, the NHI-proponents reduced the ambition of their reform proposals and made them less regulatory and redistributive. Moreover, in order to lower the reform hurdles, the NHI-proponents successfully demanded the revision of unfavorable legislative rules (in Switzerland and in the Netherlands) or skillfully reinterpreted legislative rules (in the United States). Those strategies allowed them to use more favorable legislative procedures and enabled them to successfully pass a NHI legislation.

Based on these findings, the dissertation is making a strong argument that the institutions, in this case the (private) health insurance, are not always static or overly self-perpetuating and self-preserving. On the contrary, under certain conditions institutions can unfold a self-undermining dynamic, which enables new reform coalitions and eventually leads to the reform and renewal of those institutions. Although the legislative rules structure and often hinder the agency of political actors, the legislative rules could be interpreted, enacted, and even contested in various ways creating an additional source of agency for major legislative reforms.

Dahlem Research School
Deutsche Forschungsgemeinschaft