The State as Architect of Political Order: Policy Dynamics in German Health Care

Abstract

The focus of this article is on the state as an actor that can create, rearrange or even destroy established structures of interest representation. Through small, often almost overlooked, and sometimes even failed interventions, governmental policies create a legacy that can serve as a springboard for further political action. This policy dynamic is triggered by “architectural” activities of the state, aiming at the structure of the interest group system. This kind of policy bears the potential not only to manipulate the structure, but also the preferences and strategies of interest groups so as to overcome their veto‐power. The case of German health care reform policies since the late 1970s is used to illustrate how suck a kind of governmental “design” has exerted a decisive impact on the structure of the policy field, culminating in an unexpected legislative success for the federal government.1

The Importance of Order and Complements: A New Way to Understand the Dutch and German Health Insurance Reforms

“…However, in situations where defenders of the status quo are equipped with strong and numerous veto possibilities, reformist actors will find it difficult to mobilize resources and assemble coalitions that support any radical institutional change (Immergut 1992;Pierson 2004). Here we should emphasize an important difference between the unitary state of the Netherlands and the federal polity of Germany, where the position of the Länder in the upper parliamentary chamber, the Bundesrat, may add additional veto points to the ones discussed in the political context (Döhler 1995). The more general point, however, is that next to the importance of intracoalitional consensus in the political arena, the extent to which the state and societal actors (sickness funds and private health insurers) involved in health care are able and willing to reach consensus on the general direction of reforms also matters.…”

The Organization of Health Policy Functions in the German Federal Government

“…Thus, politicians have failed to reach their declared goal of cost containment, unsurprisingly under demographic and labour market pressures and under conditions of evolving medical technology, but this does not mean that their reform attempts had left no mark on the policy field (Döhler 1991: 497). On the contrary, state activism – for better or for worse – has done much to alter self‐government structures and corporatist regulation of the policy field (Döhler 1995).…”

The complexity of governance change: reforming the governance of medical performance in Germany

“…The literature refers to such developments as 'Korporatisierung' (Dö hler, 1995;Dö hler and Manow, 1997), whereby the joint selfadministration extends its scope while at the same time becoming both more standardized and centralized. As mentioned above, the Medical Centre for Quality as a non-statutory organization run jointly by several medical organizations initially occupied this niche.…”

“…The government is also quite active as an 'architect of political order' (Dö hler, 1995), creating institutional spaces for intervention. These forms of governance have traditionally been weak and have focused on the procedural aspects of setting the framework of the joint self-administration.…”