The American Congress and health care policies

Jusqu'au passage du Patient Protection and Affordable Care Act de 2010, loi réformant structurellement le système de santé américain, les politiques d'assurance santé aux Etats-Unis sont apparues comme particulièrement difficiles à réformer. Parmi les facteurs expliquant la résistance de ce secteur aux changements, des éléments institutionnels, tenant dans la configuration du système politique américain et dans un régime fédéral de séparation des pouvoirs, apparurent accentuer ces blocages. Cette thèse aborde cette question en réfléchissant à l'impact du Congrès américain dans la construction et dans les réformes du système de santé américain. Elle propose d'analyser l'implication des scènes législatives américaines dans ce secteur à partir d'une approche historique et qualitative mettant en relation les évolutions internes de la branche législative et la trajectoire des politiques d'assurance santé. L'objectif de cette recherche est d'aborder cette question en reliant deux sous-disciplines de la science politique : les études sur le Congrès d'une part, les analyses des politiques sociales d'autre part. Plus généralement, cette thèse aborde la question des rapports entre la politique (politics) et les politiques (policies) qui se donnent à voir au sein des scènes législatives. Constatant une accélération des réformes à partir des années 1990, elle soutient que les inflexions récentes qu'ont connues les politiques de santé trouvent leur explication dans l'évolution de l'organisation du Congrès et dans un certain renforcement de ses composantes partisanes.Until the vote of the Patient Protection and Affordable Care Act of 2010, a law that structurally reformed the American health care system, important obstacles to change characterized health care policies in the United States. Among the explanations of the gridlock inherent to this policy sector, institutional features of the American political system - a federal regime of separation of power - appeared increasing these gridlocks. This dissertation tackles this question in focusing on the impact of the Congress on the development of the American health car system. Using an historical institutionalist and a qualitative approach, it offers an analysis of the legislative branch's involvement in this issue. For that purpose, this research links internal evolutions of the Congress and the development of health care policies. This research binds two subfields of political science : Congressional studies on one hand, health care analysis on the other hand. More generally, this dissertation approaches the question of the relationships between legislative politics ans health care policy. Noticing icreased reforms from the 1990s on, it supports the idea that recent inflexions are explained by an evolution of the internal organization of the Congress and by e recent strenghening of its parties

Kingdon en Afrique ? Théories de la mise sur agenda et le développement d’un programme d’assistance santé au Burkina Faso: Commentaire

L'article de Kadio et al., relatif à l’émergence et à la formulation d’une politique d’assistance santé au Burkina Faso, analyse le processus de mise sur agenda d’un programme de subventions pour aider les populations démunies à s’assurer auprès de mutuelles volontaires de santé. Sa particularité est de s’intéresser aux dynamiques politiques nationales ayant conduit à la mise en œuvre de cette politique, un angle qui est assez peu développé dans les recherches actuelles. Centré sur les acteurs et sur les processus de construction des problèmes publics, il mobilise la théorie de la mise sur agenda de John Kingdon (2003), une notion construite aux États-Unis et qui a depuis été très largement adoptée dans l’analyse des politiques publiques d’autres pays. (Premier paragraphe de l'article

Le temps d’une assurance maladie universelle est-il venu ?: [contribution au numéro spécial: États-Unis, quel renouveau à gauche?]

Dix ans après l’Obamacare, le système de santé étasunien reste l’un des plus chers et des plus inégalitaires de l’OCDE. La réforme de 2010 a néanmoins ouvert la voie à l’idée d’une assurance maladie universelle. Cette solution peut-elle prévaloir sur l’option publique, un approfondissement de l’Obamacare défendu par les modérés du parti démocrate

L'Obamacare au temps de Trump

Dix ans après son passage, toujours relativement intacte malgré les nombreuses tentatives républicaines d’abrogation totale ou partielle, l’Obamacare a permis de ralentir la croissance des dépenses de santé et d’améliorer significativement l’accès aux soins de la population. Elle a permis à près de 20 millions de personnes qui en étaient privées auparavant d’obtenir une assurance santé. Trente millions de personnes restent néanmoins non assurées, loin des promesses d’une couverture médicale « quasi » universelle entendues dans les discours démocrates en 2010. Quelques mois avant les élections présentielles de novembre 2020 et en pleine pandémie de Covid-19, ces limites appellent à réformer la réforme. Cet article revient sur les avancées et sur les limites de l’Obamacare dix ans après son vote, ainsi que sur les inflexions menées sous les républicains

Public Health in a cross-national Lens: the surprising strength of the American System

Critics of the US health system argue that a higher proportion of the health dollar should be spent on public health, both to improve outcomes and to contain costs. Attempts to explain the subordinate status of public health in America highlight such factors as distrust in government, federalism, and a bias toward acute care. This article considers these assumptions by comparing public health in the United States, England, and France. It finds that one common variable is the bias toward acute care. That the United States has such a bias is not surprising, but the similar pattern cross-nationally is less expected. Three additional findings are more unexpected. First, the United States outperforms its European peers on several public health metrics. Second, the United States spends a comparable proportion of its health dollar on prevention. Third, these results are due partly to a federalism twist (while all three nations delegate significant responsibility for public health to local governments, federal officials are more engaged in the United States) and partly to the American version of public health moralism. We also consider the renewed interest in population health, noting why, against expectations, this trend might grow more quickly in the United States than in its European counterparts

Mobilizing risk:Explaining policy transfer in food and occupational safety regulation in the UK

Using comparative methods of policy analysis, this paper explores the institutional factors shaping the transfer and adaptation of risk-based approaches to regulation within and between the regimes for occupational health and safety (OHS) and food safety in the UK. Over the past two decades successive governments have enthusiastically promoted risk as a key concept for regulatory reform and ‘better regulation’. Rather than trying to prevent all possible harms, ‘risk-based’ approaches promise to make regulation more proportionate and effective by using various risk-based metrics and policy instruments to focus regulatory standard-setting and enforcement activity on the highest priority risks, as determined through formal assessments of their probability and consequences. But despite facing similar external pressures and sharing many historical and structural features as OHS, food safety regulation has proven much less receptive to risk-based reforms of its organizing principles and practices. To explain that anomaly, we consider a range of explanations highlighted in the policy transfer and mobilities literatures. We find that coercive drivers for the adoption of risk, in the form of top-down political pressure for deregulation or hard EU mandates, are much less influential than voluntary ones, which reflect both normative (ie, shared commitments to proportionality, resource prioritization, and blame deflection) and mimetic (ie, imitation of private sector corporate governance models) isomorphism. We conclude with wider reflections about the significance of our cases for policy transfer and mobilities research and for the limits to risk as a universal principle for organizing, and accounting for, governance activity. </jats:p

Accounting for failure:risk-based regulation and the problems of ensuring healthcare quality in the NHS

In this paper, we examine why risk-based policy instruments have failed to improve the proportionality, effectiveness, and legitimacy of healthcare quality regulation in the National Health Service (NHS) in England. Rather than trying to prevent all possible harms, risk-based approaches promise to rationalise and manage the inevitable limits of what regulation can hope to achieve by focusing regulatory standard-setting and enforcement activity on the highest priority risks, as determined through formal assessments of their probability and consequences. As such, risk-based approaches have been enthusiastically adopted by healthcare quality regulators over the last decade. However, by drawing on historical policy analysis and in-depth interviews with 15 high-level UK informants in 2013–2015, we identify a series of practical problems in using risk-based policy instruments for defining, assessing, and ensuring compliance with healthcare quality standards. Based on our analysis, we go on to consider why, despite a succession of failures, healthcare regulators remain committed to developing and using risk-based approaches. We conclude by identifying several preconditions for successful risk-based regulation: goals must be clear and trade-offs between them amenable to agreement; regulators must be able to reliably assess the probability and consequences of adverse outcomes; regulators must have a range of enforcement tools that can be deployed in proportion to risk; and there must be political tolerance for adverse outcomes