Redéfinir le rôle de l’État dans le soins de santé: une analyse comparative de l’Italie et des États-Unis

In highly decentralized political systems such as found in Italy and in federal countries as in the United States of America (US), the economic and financial crisis beginning in 2008 gave way to a more assertive role of the central government in various policy areas including health. In the case of the Italian National Health Service (NHS), the central government – under pressure by the European Union and financial markets– intensified earlier efforts to impose cost containment policies, partially re-centralizing the policy-making process and strictly limiting the financial and organizational autonomy of Regions with high deficits. In the case of the Private Health insurance (PHI) system of the US, the economic turmoil of 2008 onwards provided a context in which dramatic federal health reform would unfold with the passing of the Patient Protection and Affordable Care Act (ACA) of 2010. In comparative terms, the Italian and the US cases represent two highly dissimilar systems that responded to problem pressure with similar recourse to the regulatory apparatus of central government, however, to different ends: in Italy, recentralization aimed at better cost containment of regional spending on health care in order to compensate for larger economic deficits; whereas in the US, the assertion of the central government’s role as regulator was aimed at welfare state expansion. Where the two systems converge is in the global economic climate of crisis that took off in 2008, as well as in the intergovernmental setting in which they operate –namely, the highly regionalized political context of health care policy in Italy and the federal system of the US. Following the logic of a Most Different Systems Design (MDSD) (Przeworski and Tuene 1970; Peters 1998), the present comparative study asks, what role do the financial crisis and the analogous intergovernmental context surrounding healthcare policy play in explaining the recentralization observed between two highly divergent system types? In order to answer this question, we will first describe developments in the changing role of the state for each case during the post-2008 period, particularly with a view to earlier evidence of regulatory hybridization in line with Rothgang et al. (2010) and Frisina Doetter et al. (2015). Once described, we seek, in a second step, to explain the emergence of recentralization, focusing on the role of the financial crisis and intergovernmental politics, as these variables interact with system-specific deficits and problem pressure to define the course of regulatory changes. The study uses qualitative methods of process tracing, relying on primary and secondary literature. The chapter is organized as follows: after outlining core theoretical assumptions regarding the changing role of the state in health care, as well as the research design and methods, findings for the Italian and US case studies will be presented separately before being drawn into comparative perspective. The paper concludes by reflecting on the need of revising the concept of hybridization to allow for a greater analytical focus on territorial shifts in power that reflect intergovernmental ties, which is key to understanding developments in healthcare systems within highly decentralized political contexts.