Policy feedback, varieties of federalism, and the politics of health‐care funding in the United States, Mexico, and Canada

The United States lies somewhere in the middle of Mexico and Canada in terms of fiscal and political decentralization.

“The United States lies somewhere in the middle of the two countries in terms of fiscal and political decentralization (Requejo, 2010;Watts, 1999).”

• cites Requejo, 2010 sourcePartly supported

  Table 2 (Additional information; page unavailable) places the United States between Mexico and Canada on the overall decentralization scale: 14.5, versus 5 and 16.5. Section 3.2 says that scale combines political powers with an economic-decentralization measure, but the available figures do not establish the same three-country ordering for fiscal decentralization separately. (LLM, conf=0.83)

  Experimental — accuracy not yet measured
• cites Watts, 1999Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The 2023 appropriations legislation's unwinding of emergency Medicaid expansion was projected to result in the disenrollment of as many as 14 million people from Medicaid coverage in 2023.

“This policy change was projected to result in the disenrollment of as many as 14 million people from Medicaid coverage in 2023 (Tolbert & Ammula, 2023).”

• cites Tolbert & Ammula, 2023Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Although REPSS were designed to exist outside state health agencies to separate financing from provision, they were in practice administratively and politically dependent on state governments.

“Although REPSS were designed to exist outside of the state health agencies, in order to separate financing from provision, as a mechanism to improve the efficiency and quality of service delivery, they were, in practice, administratively (and politically) dependent on state governments (Flamand & Moreno-Jaimes, 2014, 2015).”

• cites Flamand & Moreno-Jaimes, 2014, 2015Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

There has been a massive increase in fiscal transfers from the federal government to state governments in the United States.

“The result has been a massive increase in fiscal transfers from federal to state governments (Office of Management and Budget, 2016).”

• cites Office of Management and Budget, 2016Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Medicaid enrollment increased by nearly 25% between February 2020 and January 2022.

“Medicaid enrollment increased by nearly 25% between February 2020 and January 2022 (Centers for Medicare and Medicaid Services, 2022).”

• cites Centers for Medicare and Medicaid Services, 2022Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Oregon's experiment in expanding Medicaid eligibility to all uninsured poor adults failed to stick.

“Among other important examples, Oregon's experiment in expanding eligibility to all uninsured poor adults-despite backing from a broad bipartisan coalition-failed to stick.”

• cites Oberlander, 2006 sourceNot checked — no full text of the source

In Canada, the lack of an annual escalator for health transfers between 1995 and 2004 created considerable instability in federal-provincial relations.

“In Canada, the lack of an annual escalator for health transfers between 1995 and 2004 created considerable instability in federal-provincial relations.”

States that participated in Medicaid expansion were statistically significantly more likely to see larger enrollment increases during the first year of the pandemic than those that did not participate, even when controlling for important enrollment drivers such as higher rates of unemployment.

“States that participated in Medicaid expansion were, for example, statistically significantly more likely to see larger enrollment increases during the first year of the pandemic than those which did not participate-even when controlling for important enrollment drivers, such as higher rates of unemployment (Clemens et al., 2021).”

• cites Clemens et al., 2021 sourceNot checked — no full text of the source

Medicaid has become the single largest intergovernmental program in the United States.

“While its creators did not intend it, Medicaid has become the single largest intergovernmental program in the country, which explains its growing importance for intergovernmental relations.”

Canada did not witness any major shift in the basic intergovernmental structure of fiscal federalism for health-care funding.

“Third, in contrast to the United States and Mexico, Canada did not witness any major shift in the basic intergovernmental structure of fiscal federalism for health-care funding, a situation directly related to the relative lack of self-undermining feedback effects, which points to strong institutional stability.”

States have already begun to process Medicaid eligibility redeterminations in highly divergent ways.

“states have already begun to process eligibility redeterminations in highly divergent ways (Buettgens & Green, 2022;Kaiser Family Foundation, 2023).”

• cites Buettgens & Green, 2022Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Kaiser Family Foundation, 2023Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Between 1971 and 2021, Medicaid spending increased by 1400%.

“Between 1971 and 2021, Medicaid spending increased by 1400%”

• cites MACPAC, 2022, p. 25Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The U.S. Medicaid system is characterized by an extraordinary degree of state-level variation in benefits, eligibility, rules, and restrictions.

“In terms of policy legacies, the system is thus characterized by an extraordinary degree of state-level variation in benefits, eligibility, rules, and restrictions.”

Republican governors, with some exceptions, tended to refuse Medicaid expansion, leaving millions of dollars in intergovernmental transfers on the table.

“Republican governors-with some exceptions-tended to refuse Medicaid expansion, leaving millions of dollars in intergovernmental transfers on the table (Béland et al., 2016).”

• cites Béland et al., 2016Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Today, the federal government accounts for 72% of all Medicaid spending.

“today, the federal government accounts for 72% of all Medicaid spending (MACPAC, 2022, p. 25).”

• cites MACPAC, 2022, p. 25Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Before the elimination of SP, there were tensions between the federal and state government over the control of resources.

“Before this elimination, there were tensions between the federal and state government over the control of resources.”

Further changes in 2007 intended to stimulate states' tax revenue and diminish fiscal imbalances achieved practically no improvements.

“Further changes in 2007, intended to stimulate states' tax revenue and diminished such fiscal imbalances, achieved practically no improvements (Mendoza, 2019;Pérez & Villarreal Páez, 2019).”

• cites Mendoza, 2019Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Pérez & Villarreal Páez, 2019Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The federal government was obligated to put health funding at the top of the agenda in each of the first ministers' meetings it reluctantly convened.

“but was obligated to put health funding at the top of the agenda in each of the meetings reluctantly convened by the federal government.”

Between 1995 and 2004, provincial premiers made continual demands on the prime minister for first ministers' meetings to discuss increases in health transfers.

“This is why, between 1995 and 2004, provincial premiers made continual demands on the prime minister for first ministers' meetings to discuss increases in health transfers.”

The federal government resisted provincial premiers' requests for first ministers' meetings on health transfer increases.

“Naturally, the federal government resisted such requests”

Different patterns of policy feedback help account for major changes in the intergovernmental politics of fiscal federalism in health care taking place in the United States and Mexico but not in Canada.

“As our evidence suggests, different patterns of policy feedback help account for the fact that major changes in the intergovernmental politics of fiscal federalism in health care took place in the United States and Mexico but not in Canada.”

Policy feedback shapes the varieties of federalism in North American public health-care funding before and during the COVID-19 crisis.

“We argue that policy feedback shapes the “varieties of federalism” in North American public health-care funding before and during the COVID-19 crisis.”

Existing fiscal policies shape the politics of health-care funding at both the federal and subnational level through both self-reinforcing and self-undermining feedback effects.

“The following analysis suggests that existing fiscal policies shape the politics of health-care funding at both the federal and the subnational level through both self-reinforcing and self-undermining feedback effects.”

Over the last century, federal and state authority in the United States has become increasingly imbricated.

“One reason for this is that, over the last century, federal and state authority has become increasingly imbricated.”

Different institutional legacies shape current conflicts over federal health-care funding in the United States, Mexico, and Canada.

“Grounded in a historical institutionalist perspective, the article shows how different institutional legacies shape current conflicts over federal health-care funding in these three highly dissimilar federal countries.”

The distinct nature of policy feedback effects in the United States, Mexico, and Canada helps explain why the United States and Mexico recently witnessed major changes in intergovernmental relations over fiscal federalism for health care while Canada did not.

“More specifically, the article shows how the distinct nature of policy feedback effects in the United States, Mexico, and Canada helps explain why the two former countries recently witnessed major changes in intergovernmental relations over fiscal federalism for health care while the latter did not.”

Self-undermining and/or self-reinforcing feedback mechanisms have shaped in distinct manners the intergovernmental politics of fiscal federalism over health-care financing in each of the United States, Mexico, and Canada.

“Using a processtracing approach and drawing on policy documents and existing scholarship, this analysis suggests that self-undermining and/or self-reinforcing feedback mechanisms have shaped in distinct manners the intergovernmental politics of fiscal federalism over health-care financing in each of the three countries under consideration.”

Medicaid's design and policy legacy affected the program's capacity to respond to the COVID-19 pandemic in two primary ways.

“Medicaid's design and policy legacy affected the program's capacity to respond to the COVID-19 pandemic in two primary ways.”

Policy feedback plays a key role in structuring the intergovernmental politics of health-care funding in the United States.

“First, policy feedback plays a key role in structuring the intergovernmental politics of health-care funding in the United States.”

Policy feedback affects the intergovernmental politics of health-care funding in the United States, Mexico, and Canada, pointing to the impact of policy feedback on a key aspect of varieties of federalism.

“The above discussion about our three cases shows that policy feedback affects the intergovernmental politics of health-care funding in each of the countries under consideration, pointing to the impact of policy feedback on a key aspect of varieties of federalism.”

Compared to Canada and the United States, Mexico is a highly centralized federation.

“Compared to Canada and the United States, Mexico is a highly centralized federation.”

Incremental, pluralistic politics facilitated the centralization of resources and authority in U.S. Medicaid.

“Yet, while an incremental, pluralistic politics facilitated this centralization of resources and authority, the nationalization of politics has created an intense, polarized conflict over the boundaries and content of state Medicaid programs.”

In 2004, the Mexican federal government implemented Seguro Popular to provide publicly funded health insurance to an otherwise uninsured population, covering a limited set of health-care interventions and medicines.

“In 2004 the federal government implemented SP to provide publicly funded health insurance to an otherwise uninsured population, which covered a limited set of health-care interventions and medicines (Murayama & Martínez, 2016).”

• cites Murayama & Martínez, 2016Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

In Mexico, the flaws in design and functioning of SP, in conjunction with political and institutional factors at state and federal levels, propitiated negative policy feedback effects that facilitated its elimination in 2020.

“Second, in Mexico, the flaws in design and functioning of SP, in conjunction with political and institutional factors at state and federal levels, propitiated negative policy feedback effects that facilitated its elimination in 2020.”

In the last two decades, the nature of Mexican federalism and self-undermining policy feedback provoked the emergence of a pattern of decentralization-recentralization in the Mexican health-care system.

“This suggests that, in the last two decades, the nature of Mexican federalism (i.e., the impact of authoritarian legacies in the states) and self-undermining policy feedback (i.e., the poor health-care performance in the states and the wrongdoing in the use of financial resources) provoked the emergence of a pattern of decentralization-recentralization in the Mexican health-care system.”

President AMLO took advantage of the negative policy effects of SP to justify the recentralization of the public health-care services.

“In other words, he took advantage of the negative policy effects of SP to justify the recentralization of the public health-care services.”

The end of enhanced matching and continuous coverage requirements is likely to result in over 15 million adults and children losing Medicaid coverage.

“While the end of the enhanced matching and continuous coverage requirements is likely to result in over 15 million adults and children losing Medicaid coverage”

• cites Buettgens & Green, 2022Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Kaiser Family Foundation, 2023Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Medicaid's fiscal structure has made it an attractive vehicle for state and federal policy makers to fill the gaps left in the fragmented U.S. system of insurance provision.

“In terms of policy design, the program's fiscal structure has made it an attractive vehicle for state and federal policy makers to fill the gaps left in the fragmented U.S. system of insurance provision.”

Canada's current stability can be traced back to the creation in 1977 of a block transfer regime, which created an intergovernmental dynamic between the federal government and the provinces that has remained in place ever since.

“This current stability can be traced back to the creation in 1977 of a block transfer regime, which created an intergovernmental dynamic between the federal government and the provinces that has remained in place ever since.”

In 2012, the Supreme Court ruled that states could opt out of Medicaid expansion.

“Because of high-profile litigation in 2012, the Supreme Court ultimately ruled that states could opt out of Medicaid expansion (Béland et al., 2016).”

• cites Béland et al., 2016Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Intergovernmental relations relative to health-care funding are imbalanced toward the federal government in Mexico due to the historical concentration of political and administrative power in the federal government and the high dependence of states on federal transfers.

“Furthermore, unlike in American and Canadian federalism, the intergovernmental relations relative to health-care funding are imbalanced toward the federal government in Mexico due to, in general, the historical concentration of political and administrative power in the federal government, and, in particular, to the high dependence of states on federal transfers.”

As the federal government's role expanded in the mid-twentieth century, health care emerged as a central focus of intergovernmental conflict in the United States.

“As the federal government's role expanded in the mid-twentieth century, health care emerged as a central focus of intergovernmental conflict.”

Medicaid's financing arrangements have generally been a source of stability for the program through self-reinforcing feedback mechanisms.

“Even so, Medicaid's financing arrangements have generally been a source of stability for the program through self-reinforcing feedback mechanisms.”

Following major legislative victories for Democrats and accommodations for private-sector opponents, Congress enacted the Medicare and Medicaid programs in 1965.

“Yet following major legislative victories for Democrats, coupled with accommodations for important private-sector opponents of the program, Congress enacted the Medicare and Medicaid programs in 1965 (Berkowitz, 2005).”

• cites Berkowitz, 2005Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The nationalization of politics has created an intense, polarized conflict over the boundaries and content of state Medicaid programs.

“Yet, while an incremental, pluralistic politics facilitated this centralization of resources and authority, the nationalization of politics has created an intense, polarized conflict over the boundaries and content of state Medicaid programs.”

The emergence of health care as a central intergovernmental conflict in the United States was partly caused by policy feedback from the United States' haphazard health-care financing arrangements.

“This outcome was by no means foreordained.Rather, it emerged partly because of policy feedback caused by the United States' haphazard health-care financing arrangements.”

As initially designed, the Affordable Care Act required states to extend Medicaid coverage to all uninsured individuals with incomes up to 138% of the federal poverty level.

“As initially designed, the ACA required states to extend Medicaid coverage to all uninsured individuals with incomes up to 138% of the federal poverty level.”

This policy feedback effect relates to the nature of Canadian federalism, in which executive federalism and direct bargaining between Ottawa and the provinces are central.

“This policy feedback effect relates to the nature of Canadian federalism, in which executive federalism and direct bargaining between Ottawa and the provinces”

Because of pre-existing federal subsidies for employer-sponsored insurance arrangements, numerous attempts to create a national, universal health-care plan in the United States failed.

“Because of pre-existing federal subsidies for employer-sponsored insurance arrangements, numerous attempts to create a national, universal health-care plan were met with failure (Hacker, 2004).”

• cites Hacker, 2004 sourceNot checked — no full text of the source

Self-undermining policy feedback led to a clear shift from decentralization to recentralization in the Mexican health-care system.

“Here we can clearly talk about self-undermining policy feedback (Jacobs & Weaver, 2015), leading to a clear shift from decentralization to recentralization.”

• cites Jacobs & Weaver, 2015Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The fractured U.S. approach to financing health care created gaps into which a growing number of Americans fell.

“One reason for this is that the fractured U.S. approach to financing health care has created gaps into which a growing number of Americans have fallen.”

Under Canada's stable and self-reinforcing policy regime, provincial governments bore greater fiscal risk in terms of the transfer keeping up with health-sector inflation.

“Under this stable and self-reinforcing policy regime, although no longer subject to detailed monitoring by the federal government, especially under the federal Hospital Insurance and Diagnostic Services Act, provincial governments bore greater fiscal risk in terms of the transfer keeping up with health-sector inflation.”

As gaps opened, Medicaid offered policy advocates and lawmakers a unique opportunity structure, unleashing a self-reinforcing feedback effect.

“As gaps opened, the Medicaid program offered policy advocates and lawmakers a unique opportunity structure, which unleashed a self-reinforcing feedback effect.”

The three cases point to an interaction between policy feedback and varieties of federalism.

“These three cases point once again to the interaction between policy feedback, which concerns the impact of specific policies on the politics of health and social policy, and varieties of federalism”

Federations with a strong subnational authoritarian legacy and weak subnational governing capacity may experience instability in how authority for health care is allocated across levels of government.

“For example, federations with a strong subnational authoritarian legacy and weak subnational governing capacity may experience instability in how authority for health care is allocated across levels of government.”

The character of federations is deeply affected by the policy choices of politicians.

“our analysis submits that there are numerous opportunities to see the character of federations as a dependent variable, too, one which is deeply affected by the policy choices of politicians.”

Executive federalism and direct bargaining between the central government and subnational units is self-reinforcing.

“executive federalism and direct bargaining between the central government and subnational units is both self-reinforcing”

The evidence in the study suggests that particular federal structures may unleash distinctive political dynamics that affect how social policies are made.

“Even so, the evidence here suggests that particular federal structures may unleash distinctive political dynamics that affect how social policies are made.”

In Canada, a long-accepted federalist structure generates a mode of intergovernmental politics and bargaining that prevents needed policy change.

“Finally, as illustrated in the case of Canada, a long-accepted federalist structure generates a mode of intergovernmental politics and bargaining preventing needed policy change”

Since the Canada Health Transfer is the federal government's largest expenditure after national defense, it will likely be cut back like what was done in the public financing crisis of the mid-1990s.

“Since the Canada Health Transfer is the federal government's largest expenditure after national defense, it will likely be cut back like what was done in the public financing crisis of the mid-1990s.”

Unlike in Mexico and the United States, the pandemic crisis did not generate self-undermining policy feedback effects that weakened the existing federal health transfer policy in Canada.

“In other words, unlike in Mexico and the United States, the pandemic crisis did not generate self-undermining policy feedback effects that weakened the existing federal health transfer policy.”

Federations with highly nationalized and polarized politics may see subnational cleavages in access to social benefits along partisan lines, even during periods of programmatic expansion.

“By contrast, federations with highly nationalized and polarized politics may see subnational cleavages in access to social benefits along partisan lines, even during periods of programmatic expansion.”

In Canada, a long-accepted federalist structure eventually contributes to self-undermining policy feedback and demands for change.

“and eventually contributes to self-undermining policy feedback and demands for change.”

The dynamics of first ministers' meetings stripped the health file from federal and provincial health ministers and produced a single-minded focus on money and jurisdiction to the detriment of other pressing issues.

“This effectively stripped the health file from federal and provincial health ministers and produced a single-minded focus on money and jurisdiction to the detriment of other pressing issues.”

Canadian federalism is characterized by executive federalism and direct bargaining between Ottawa and the provinces as especially central.

“feedback effect relates to the nature of Canadian federalism, in which executive federalism and direct bargaining between Ottawa and the provinces are especially central.”

Executive federalism and direct bargaining between the central government and subnational units is much more prevalent in Canada than in the United States and Mexico.

“and much more prevalent in Canada than in the United States and Mexico.”

Policy legacies can, over time, generate new patterns of intergovernmental politics through both self-reinforcing and self-undermining feedback effects.

“our analysis suggests that scholarship on how federalism varies across countries should be more attentive to how policy legacies can, over time, generate new patterns of intergovernmental politics through both self-reinforcing and self-undermining feedback effects.”