The political consequences of regulatory reforms: drug rationing policies in England and France

The past few decades have seen the proliferation of regulatory agencies, expert committees, and other “non-majoritarian” institutions in Europe. Scholars tend to assume that once created, policies corresponding to these institutions persist, disrupting the existing governance structure. This thesis instead argues that policy continuity following the creation of agencies depends on the locus of regulatory decisions. Specifically, it proposes that the extent to which elected politicians are excluded from the decision-making, i.e. their level of “political insulation”, affects policy continuity. Where elected politicians are excluded from the decision-making, this enables unpopular policy choices. But such choices, once made, generate a greater counter-mobilisation, undermining policy continuity over time. By contrast, where elected politicians have the final say on decisions, they can prevent unpopular policy choices from being taken, which contributes to policy continuity. To illustrate these mechanisms, this thesis takes restricting the funding of pharmaceutical products by the healthcare system as a case of an unpopular regulatory policy and compares its development in England and France. Both countries established regulatory agencies tasked to assess the benefits of drugs for funding decisions, but the nations subsequently followed divergent trajectories. In England, high political insulation enabled policy choices that otherwise would have been too politically costly. Yet these choices, over time, led to a greater counter-mobilisation through public and electoral arenas, resulting in a partial policy reversal. By contrast, in France, low political insulation allowed ministers to choose not to follow the agency’s outputs when they considered them too politically costly; ministers also prevented rule changes that might have made more politically-costly outputs possible. The findings highlight the endogenous drivers of post-regulatory reform policy development. Contrary to the linear trajectory, where “depoliticised” agencies reinforce themselves, the thesis suggests that under certain conditions, the policies that accompany regulatory agencies can undermine themselves by becoming a source of greater politicisation