Scott L. Greer

Health law and policy in the European Union

From its origins as six western European countries coming together to reduce trade barriers, the European Union (EU) has expanded, both geographically and in the scope of its actions, to become an important supranational body whose policies affect almost all aspects of the lives of its citizens. This influence extends to health and health services. The EUs formal responsibilities in health and health services are limited in scope, but, it has substantial indirect influence on them. In this paper, we describe the institutions of the EU, its legislative process, and the nature of European law as it affects free movement of the goods, people, and services that affect health or are necessary to deliver health care. We show how the influence of the EU goes far beyond the activities that are most visible to health professionals, such as research funding and public health programmes, and involves an extensive body of legislation that affects almost every aspect of health and health care.

The territorial bases of health policymaking in the UK after devolution

For all that there is a well-entrenched sense of the differences among the different peoples of the UK, there has been surprising reluctance to accept the extent to which these differences translate into divergent public policy trajectories. That means the extent of policy divergence since devolution has been something of an uncomfortable surprise for many. Its speed, given the common heritages, similar organizations, shared problems, and pressures for convergence between the four systems might startle – in an increasingly globalized world (and medicine has long been cosmopolitan) their divergence is striking and explaining it important. If there is to be change in a mature welfare state such as that of the United Kingdom, it will most likely be through the accretion of such changes to existing systems. And, I argue, the changes reflect the distinct politics of place and the way policy makers, often insensibly, respond to their particular problems and debates in ways that vary territorially and produce territorial policy divergence that matters.

Structural Adjustment Comes to Europe: Lessons for the Eurozone from the Conditionality Debates

This article argues that the Economic Adjustment Programmes (EAPs) that came with loans to peripheral Eurozone members Greece, Ireland, Portugal, and now Cyprus, are very similar to the loans with conditionality, also known as Structural Adjustment Programs, that international financial institutions used as a policy tool in the 1980s and 1990s. It defines structural adjustment programs and then shows how Eurozone rules plus the EAPs resemble them. It then canvasses the literature evaluating structural adjustment in the developing world in order to formulate expectations for its performance in Europe. The conclusions from the large literature on structural adjustment policies suggest that the EAPs will: be badly implemented; be neutral or bad for growth; be bad for equity and the poor; have unpredictable policy consequences; and will allow incumbent elites to preserve their positions. Preliminary evidence from the four peripheral countries confirms that the same problems are afflicting EAPs.

Devolution and divergence in UK health policies

Scott Greer explores how political variation in the UK has led to differences between the health systems of its four nations since devolution

Destabilization rights and restabilization politics: Policy and political reactions to European Union healthcare services law

European Union (EU) patient mobility law creates destabilization rights: rights for citizens that would, if consistently applied, destabilize law, administration and finance for healthcare systems across the EU. This article focuses on the responses of the destabilized organizations and their efforts to restabilize their legal situation. We argue that it takes place through two decisions: a decision about whether or not to change procedures in response to the new right; and a decision about whether or not to lobby to circumscribe the new right. Our qualitative research in Germany and the UK found some differences in responses, but across the board the incumbent organizations and governments opted for very limited compliance and considerable engagement in EU politics as their preferred strategy for responding to the new destabilization rights.

Crossborder trade in health services: Lessons from the European laboratory

We find four key lessons that health policymakers and practitioners should be aware of: the potential of services liberalization to incur high transition and transaction costs; the difficulty of reconciling economic and social policy goals and the subsequent high likelihood of backlash; the tendency of rule-based systems to promote policy spillover; and the importance (and difficulty) of early monitoring in order to avoid unwanted policy outcomes. We conclude that continued awareness of new policy developments, coordination of expertise on health and trade and preemptive regulation are vital in order to deal with the expansion of crossborder trade in health services.

Foul Weather Friends: Big Business and Health Care Reform in the 1990s in Historical Perspective

Existing accounts of the Clinton health reform efforts of the early 1990s neglect to examine how the change in big business reform interests during the short period between the late 1980s and 1994 might have altered the trajectory of compulsory health insurance legislation in Congress. This article explores evidence that big employers lost their early interest in reform because they believed their private remedies for bringing down health cost inflation were finally beginning to work. This had a discouraging effect on reform efforts. Historical analysis shows how hard times during the Great Depression also aligned big business interests with those of reformers seeking compulsory social insurance. Unlike the present case, however, the economic climate did not quickly improve, and the social insurance reform of the New Deal succeeded. The article speculates, therefore, that had employer health expenditures not flattened out, continuing and even growing big business support might have neutralized small business and other opposition that contributed heavily to the failure of reform. Thus in light of the Clinton administrations demonstrated willingness to compromise with business on details of its plan, some kind of major reform might have succeeded.

The states' role under the Patient Protection and Affordable Care Act.

Federalism, in principle, combines policy innovation with stability: state involvement adapts policy to local conditions and values and permits experimentation, while federal funding and legal frameworks can give structure and financial stability to programs. While U.S. federalism has not always realized these potential benefits, the Patient Protection and Affordable Care Act (ACA) makes a better arrangement possible. For decades, statelevel coverage expansion was a leading indicator of national interest in health care reform. State initiatives to expand coverage became more numerous and visible in years before major federal debates (Leichter 1992; Fox and Iglehart 1994; Grogan 1995; Rich and White 1996). The experience of state initiatives made politicians more comfortable with both the policies and the politics of health coverage expansion and more willing to try it nationally — a pattern seen in many areas of U.S. federalism (Rabe 2008). Yet relying entirely on state initiatives for furthering health care reform proved untenable, a result of three main problems with this approach. First, while promoting local innovation, statelevel reforms inevitably increase variation across the states in coverage, cost, and system design. Some argue that such variation is inequitable because similarly situated people will receive coverage in one state but not another (Greer 2006). Second, states are constrained by federal regulations that make certain reforms

The three faces of European Union health policy: Policy, markets, and austerity

Abstract European Union health policy has long had two faces. One face was its most visible: its support for data, networks, agencies and research that promoted shared practice and health objectives in fields such as cancer and communicable disease control. The impact the first face was striking mostly because the budget was so small. A second was long its most important: its courts’ application of internal market law and regulation to health care services in pursuit of an integrated European market and freedom of movement of goods, capital, services and people. The impact of this face created EU health care politics, but ultimately had limited effects on health care systems. Since 2010, though, the reaction to financial crisis has given EU health policy a third face: a newly rigorous and intimate fiscal governance model in which member state policies and budgets will be under continuous review, and countries in extreme trouble will face elaborate loan conditions affecting health care in detail. The credibility and wisdom of these new policies is yet to be seen and will be contested, but in principle they commit member states to detailed EU oversight of their health care systems and priorities in pursuit of fiscal rigor.

How Does Decentralisation Affect the Welfare State? Territorial Politics and the Welfare State in the UK and US

The relationship between political decentralisation and the welfare state is much studied, and large-scale studies have repeatedly found that decentralised states have less generous welfare states. How do we fit that with other studies that emphasise the potential of decentralisation to raise welfare standards? This article argues that decentralisation, as a variable, is too broad and it is more efficient to focus on the structure of veto players in the central state, intergovernmental relations and intergovernmental finance. Those are the actual mechanisms that connect decentralisation to the welfare states, and they can all vary independently of decentralisation. It uses recent changes in the United States and United Kingdom as examples. The fragmentation and average weakness of the US welfare state is mostly due to a federal government riddled with internal veto points that permits considerable interstate variation and low overall average provision, while tight central control on finances in the UK means that most variation is in the organisation, rather than levels, of social services.