Developments around EU healthcare services law have been characterized by a puzzling phenomenon. Buzzing political activity in Brussels and member state officials vying to shape EU law in accordance with their respective preferences contrasts with minimal practical changes in national healthcare systems. In their article “Destabilization rights and restabilization politics: Policy and political reactions to European Union healthcare services law” published in the Journal of European Public Policy, Scott Greer and Simone Rauscher Singh explain this disjunction. Drawing on evidence from interviews with German and British public health officials, members of EU institutions and lobbyists, Scott and Simone show that the observed pattern of a broadening political activity at the European level and few actual changes on the ground is a consequence of policy-makers’ strategic choices. Given broad compliance with the patchy legal framework of EU healthcare law is costly for member states, healthcare policy-makers opt for the smallest possible change necessary to comply whenever a national practice is at odds with EU law. Relative to compliance, stepping up their political engagement at the European level to wrest back control over healthcare policy from EU institutions is far less costly for member states. Scott and Simone’s analysis shows that member states’ political engagement in Brussels does not necessarily imply their preference for European policies on healthcare services but “reflects states’ desire to restabilize healthcare law.”
Ever since the 1950s, EU member states have sought to protect national competences to organize, finance and provide healthcare from integration at the European level. Despite these efforts, the EU has a become a significant player in public health, regulating key questions on the access to and delivery of healthcare in member states. In their article “The making of a European healthcare union: a federalist perspective” published in the Journal of European Public Policy, Hans Vollaard, Hester van de Bovenkamp and Dorte Sindbjerg Martinsen explain how the EU attained authority in public health against all odds, and offer an outlook on a European healthcare union in the making. Hans, Hester and Dorte show that the free movement of goods, services and workers allowed the European Commission to expand its involvement in healthcare, complemented by the Court of Justice’s favourable interpretations of EU healthcare legislation. Member states’ use of EU fora to pursue voluntary co-operations in the health sector and their willingness to delegate competences to the EU-level in exchange for financial support further facilitated the development of a European healthcare union. However, Hans, Hester and Dorte caution that this union remains fragile. While EU officials see the Europeanization of healthcare as an “instrument to foster a European sense of belonging among the citizens of the EU member states”, evidence that a European healthcare union cultivates citizens’ loyalty toward the EU appears thin at best.
When elections are around the corner, incumbent governments face incentives to ramp up their redistributive spending to attract the support of voters, giving rise to so-called political budget cycles (PBCs). In their article “Clientelistic budget cycles: evidence from health policy in the Italian regions” published in the Journal of European Public Policy, Francesco Stolfi and Mark Hallerberg argue that clientelistic fiscal expansions prior to elections are more prevalent in jurisdictions with few employment opportunities offered by the private sector. Clientelistic public expenditures are a particularly promising strategy for incumbents seeking re-election in poorer jurisdictions with a large share of voters relying on jobs in the public sector to support their livelihoods. Francesco and Mark support their claim with original data on income and public health personnel spending in Italy’s 21 regions between 1989 and 2012. Their analysis shows that prior to elections regions with higher per-capita incomes were less likely to see increases in public health personnel spending than poorer regions. Francesco and Mark conclude that “[i]f we take into account the incentives of incumbents and voters in poorer societies, then clientelism becomes a powerful factor explaining differences in the extent of PBCs between countries at different levels of development.”