Incrementalism Revisited - The Contrasting Approaches of Italy, England and Wales and Northern Ireland Towards Legalization of Same-Sex Marriage.

We contrast the approach taken by Italy and two constituent parts of the UK (England, Wales, and Northern Ireland) toward legalization of same-sex marriage. The incrementalist theory or "step-by-step approach" first advocated by Waaldijk in 2000 predicts that states will take prescribed steps en route to same-sex marriage. The core of incrementalism is that each step (decriminalization of same-sex sexual relations, equality of treatment for gays and lesbians, civil partnership, and finally same-sex marriage) is the logical premise for and in fact necessarily leads to the next step. Reflecting on 22 years of experience, we analyze whether this has been followed in practice in the jurisdictions under study. We demonstrate that although helpful in the early stages, incrementalism does not always reflect how legal changes have occurred and in Italy's case gives no answers as to when or if same-sex marriage will be legalized.

Republican Rules of Reproduction and "Flipping the Script" on U.S. Health Care Reform.

Given the relatively conservative and marketized nature of U.S. health care reform, it remains unclear both why Republican resistance has been so intractable through much of the Affordable Care Act's (ACA's) tenure and why it has so suddenly receded into the background. This article seeks an explanatory mechanism to make sense of the ACA's changing historical fortunes, from enactment to the present. It argues that the Republican Party's "rules of reproduction," a concept of historical sociology, best explains why the ACA met with such vociferous resistance and why that resistance has given way to surprising progress on coverage. It begins with a consideration of marketized U.S. health care, as well as the ACA's quest for expanded coverage-not structural rearrangement-as the basis for progressive change. Following this, I explore the "rules of reproduction" to explain Republican political actors' relentless attacks on the law. The final section considers how the historically-contingent COVID-19 event has dovetailed with ACA entrenchment, effectively "flipping the script" on Republican rules, making anti-Obamacare maneuvers far less politically palatable. It is in this political space that reform advocates have been able to seize opportunity and broaden access.

Commentary: The Boy Who Cried Wolf or Cassandra? A Consideration of the Correct Characterization of Critics of Neoliberal Reforms to the English NHS.

Peter Roderick and Allyson Pollock's article, "Dismantling the National Health Service in England," provides a history of the market incrementalism that has dominated UK government policy pertaining to the English National Health System (NHS), in recent decades. It also contains an analysis of the latest statute to reform the English NHS, namely the Health and Care Act 2022. It is often argued that the concerns-for example, about privatization-of those who critique neoliberal reforms to the English NHS are misplaced. I highlight that such neoliberal reforms have increased the proportion of the budget of the English NHS that is being diverted to private providers. Consequently, I aver that the term privatization accurately describes what has been occurring within the English NHS. I contend that the arguments of those who deny or downplay the privatization of the English NHS are indicative of some of the ideological strategies that the sociologist John B. Thompson identified. My commentary suggests that the concerns of critics of neoliberal reforms to the English NHS, such as Roderick and Pollock, are not misplaced and that more heed should be given to their analyses and warnings.

Agenda governamental brasileira: prioridades e mudanças na dinâmica da atenção sobre a distribuição orçamentária da União (2000-2021) / Agenda del gobierno brasileño: prioridades y cambios en la dinámica de atención a la distribución del presupuesto federal (2000-2021) / Brazilian policy agenda: priorities and changes in the dynamics of attention on the federal budget distribution (2000-2021)

Resumo Os estudos sobre agenda governamental têm adotado diversos indicadores para mensurar a atenção e as prioridades dos governos, a fim de analisar os processos de formulação e mudança de políticas públicas. Com base nas prerrogativas da teoria do equilíbrio pontuado sobre os padrões de mudanças na dinâmica das políticas, a distribuição do orçamento público tem se destacado como um dos instrumentos que melhor expressam os níveis de atenção e as prioridades dos governos em diferentes setores. Nesse contexto, alinhado a uma agenda internacional, este estudo busca investigar o padrão da atenção governamental acerca da distribuição orçamentária no Brasil. Assim, o objetivo deste trabalho é mapear a dinâmica da atenção governamental sobre a disposição do orçamento aprovado da União ao longo das últimas duas décadas (2000-2021), identificando os níveis percentuais de atenção aos diferentes setores de políticas públicas ao longo do tempo e os fatores conjunturais e institucionais que balizam os níveis de atenção governamental na classificação orçamentária. Para isso, foi formulado um banco de dados do orçamento aprovado de 2000 a 2021, no qual as 814 combinações de funções e subfunções de gastos foram codificadas em 21 setores, conforme metodologia do comparative agenda project (CAP). Os resultados indicam que a atenção governamental sobre essa distribuição opera sob um padrão majoritariamente incremental no decorrer do tempo, mas permeado por pontuações no equilíbrio em políticas setoriais específicas, comprovando a teoria do equilíbrio pontuado (punctuated equilibrium theory [PET]) no cenário nacional. De igual modo, apontam para a necessidade de mais estudos setoriais que expliquem as causas e os efeitos das pontuações na atenção governamental, suas relações com mudanças na agenda legislativa e os impactos de momentos de crises institucionais na definição de prioridades na distribuição orçamentária, apontados como agendas futuras a partir deste trabalho.

Resumen Los estudios sobre la agenda gubernamental adoptaron varios indicadores para medir la atención y las prioridades de los gobiernos a los efectos de analizar los procesos de formulación y cambio de políticas públicas. Desde las prerrogativas de la teoría del equilibrio puntuado sobre los patrones de cambios en la dinámica de las políticas, la distribución del presupuesto público se ha destacado como uno de los instrumentos que mejor expresan los niveles de atención y las prioridades de los gobiernos de los diferentes sectores. En ese contexto, de acuerdo con una agenda internacional, este estudio busca investigar cuál es el patrón de atención gubernamental respecto a la distribución presupuestaria en Brasil. Así, el objetivo de este trabajo es mapear la dinámica de atención gubernamental sobre la distribución del presupuesto federal aprobado en las últimas dos décadas (2000-2021), identificando (i) cuáles son los niveles porcentuales de atención a los diferentes sectores de las políticas públicas a lo largo del tiempo y (ii) los factores coyunturales e institucionales que orientan los niveles de atención del gobierno en la clasificación presupuestaria federal. Para ello, se creó una base de datos del presupuesto aprobado de 2000 a 2021, en la que se codificaron las 814 combinaciones de funciones y subfunciones del gasto en 21 sectores, según la metodología del Proyecto de Agenda Comparada (CAP). Los resultados indican que la atención del gobierno sobre la distribución del presupuesto opera en un patrón mayoritariamente incremental en el tiempo, pero permeado por puntajes de equilibrio en políticas sectoriales específicas, demostrando así la teoría del equilibrio puntuado a nivel nacional. Asimismo, señalan la necesidad de mayores estudios sectoriales que expliquen las causas y efectos de los puntajes en la atención del gobierno, sus relaciones con los cambios en la agenda legislativa y los impactos de los momentos de crisis institucional en la definición de prioridades en la distribución presupuestaria, identificadas como futuras agendas a partir de este trabajo.

Abstract Studies on policy agenda have adopted several indicators to measure the attention and priorities of governments to analyze the processes of policy change and policy dynamics. Based on the Punctuated Equilibrium Theory (PET) applied on the patterns of policy change, the distribution of the public budget has stood out as one of the instruments that best express the levels of attention and priority for governments in different sectors. This study seeks to investigate the pattern of government attention on the federal budget distribution in Brazil. Thus, this work maps the dynamics of government attention on the distribution of the federal approved budget over the last two decades (2000-2021), identifying (i) what are the percentage levels of attention to the different sectors of public policies over time and (ii) the conjunctural and institutional factors that guide the levels of government attention in the budget distribution of the federal government in Brazil. A database of the federal approved budget from 2000 to 2021 was created, in which the 814 combinations of expenditure functions and subfunctions were coded into 21 sectors according to the methodology of the Comparative Agenda Project (CAP). The results indicate that government attention on the distribution of the Brazilian federal budget operates in a mostly incremental pattern over time, permeated by punctuations in specific sectoral policies, thus proving the Punctuated Equilibrium Theory at the national level. As for future research agenda, the study shows the need for further sectoral studies that explain the causes and effects of changes on government attention, their relationships with the legislative agenda, and the impacts of moments of institutional crisis in defining priorities in budget distribution.

Academic medical centres in the Netherlands: muddling through or radical change?

Introduction: Academic medical centres (AMCs) are designed to perform multiple tasks within a single organisation. This institutional complexity gives rise to intricate governance challenges and promotes incrementalism and muddling. Method: In this study, we hypothesised that radical change could provide a solution to the current incrementalism and we explored the conditions under which such changes could or could not be achieved. Results: We conducted unstructured interviews with various high-level stakeholders and identified issues that negatively affected the governance of Dutch AMCs, which include: 1) negative undercurrents and unspoken issues due to conflicts of interests, 2) organisational complexity due to relationships with a university and academic medical specialists, 3) lack of sufficient government direction, 4) competition between AMCs due to perverse systemic incentives, 5) different interests, focus, and organisational culture, 6) concentration of care, which does not always lead to enhanced quality and efficiency as the provision of less complex care is of utmost importance for education and research, 7) the infeasibility of public and regional functions of an AMC, 8) the inefficiency of managing three core tasks within the same organisation and, 9) healthcare market regulation. Discussion: Our hypothesis that radical change offers a solution to the current incrementalism in AMCs could not be adequately explored. Indeed, our exploration of the conditions under which radical change could potentially take place revealed that there are factors currently at play that make a substantive conversation between stakeholders about radical change difficult, if not impossible. The results also show that the government is in a position to take the lead and create conditions that foster mutual trust and common interests among AMCs, as well as between AMCs and other hospitals.

Policy programs and service delivery models for older adults and their caregivers: Comparing three provinces and two states.

Despite an increase in prevalence of complex chronic conditions and dementia, long-term care services are being continuously pushed out of institutional settings and into the home and community. The majority of people living with dementia in Canada and the United States (U.S.) live at home with support provided by family, friends or other unpaid caregivers. Ten dementia care policy programs and service delivery models across five different North American jurisdictions in Canada and the U.S. are compared deductively using a comparative policy framework originally developed by Richard Rose. One aim of this research was to understand how different jurisdictions have worked to reduce the fragmentation of dementia care. Another aim is to assess, relying on the theory of smart policy layering, the extent to which these policy efforts 'patch' health system structures or add to system redundancies. We find that these programs were introduced in a manner that did not fully consider how to patch current programs and services and thus risk creating further system redundancies. The implementation of these policy programs may have led to policy layers, and potentially to tension among different policies and unintended consequences. One approach to reducing these negative impacts is to implement evaluative efforts that assess 'goodness of fit'. The degree to which these programs have embedded these efforts into an existing policy infrastructure successfully is low, with the possible exception of one program in NY.

Small steps, big change. Forging a public-private health insurance system in the Netherlands.

CONTEXT: History helps us to better understand the particulars of the form and functions of institutions. In this paper we present the case study of the evolution of health care financing in the Netherlands over the past 150 years, through the lens of incremental institutional change. METHODS: Our historical and political analysis is based on a review of secondary literature as well as relevant policy documents, parliamentary debates and archival material. We use the conceptual framework of incremental institutional change (i.e. layering, conversion, drift and displacement) for our analysis. FINDINGS: The constitutional program of the mid-nineteenth century laid down the foundations of a 'private initiative first, government last'-approach to health care financing in the Netherlands. Over the course of 150 years this led to the evolution of a complex layered system of financial arrangements consisting of direct public funding, national, social and private health insurance with complex interdependencies. This was not a conscious strategy, but a result of the fact that the central government in the Netherlands preferred to tackle specific problems in health care financing with very specific measures, so as not to intrude on the trade of civil society and commercial business in health care. CONCLUSIONS: Regulatory authority and statist power in and over health care financing is not something that was created through dramatic reform in the Netherlands, but came about through many decades of small, incremental, yet accumulating changes. This provides a case study for further analysis of incremental versus rapid change in health care systems internationally.

Radical Incrementalism and Trust in the Citizen: Income Security in Canada in the Time of COVID-19.

This article documents Canada's main public policy responses to promote income security among working-age adults during the coronavirus disease 2019 (COVID-19) crisis between March and early June 2020. This period of rapid policy change unfolded broadly in three phases, starting with minor adjustments to existing policy instruments, followed by larger amendments to a wider range of programs, and finally ending with the creation of new and quite generous benefits. The pathway of policy change is best described as incremental, but it resulted in a more radical shift to "trust but verify" to administer benefits rather than the pre-COVID-19 practice of verifying eligibility before paying benefits. The reasons and precedents for this decision are discussed. I conclude with some observations on the applicability and limitations of trust but verify for income security policy in the post-COVID-19 period.

L'auteure documente les principales mesures politiques prises par le Canada afin de promouvoir la sécurité du revenu chez les adultes en âge de travailler durant la crise de la maladie du coronavirus (COVID-19), entre mars et le début de juin 2020. Cette période d'évolution rapide des politiques s'est essentiellement déroulée en trois phases : en premier lieu, des ajustements mineurs aux instruments politiques existants, suivis de modifications plus importantes à un plus large éventail de programmes et, pour finir, la création de prestations nouvelles et très généreuses. On pourrait décrire cette évolution des politiques comme étant progressive, mais elle a débouché sur un virage plus radical vers une pratique de type « faire confiance, mais vérifier ¼ dans l'administration des prestations, plutôt que la pratique antérieure à la COVID-19 qui consistait à vérifier l'admissibilité avant de verser les prestations. L'auteure traite des raisons et des précédents de cette décision. Elle conclut par des observations sur l'applicabilité et les limites de la pratique consistant à faire confiance mais à vérifier en ce qui a trait à la politique de sécurité du revenu, dans la période postérieure à la COVID-19.

Democratização e reforma do Estado: o desenvolvimento institucional dos tribunais de contas no Brasil recente / Democratization and state reform: the institutional development of the courts of accounts in recent Brazil

Este artigo analisa as transformações das últimas décadas nos tribunais de contas no Brasil, à luz da discussão da temática do desenvolvimento institucional. Essa perspectiva analítica permite olhar os processos de mudanças nas arenas políticas, no longo prazo, enfatizando não só a resistência dos atores institucionais ou sociais com poder de veto e os mecanismos de path dependence, mas igualmente as conjunturas críticas que permitem levar adiante as transformações, mesmo que de forma incremental. No caso em estudo, a conjuntura crítica da democratização e da Constituição de 1988 trouxe mudanças, mas estas foram neutralizadas pela capacidade de veto da elite dirigente especialmente em alguns tribunais. Por outro lado, a nova conjuntura crítica representada pela Lei de Responsabilidade Fiscal, de 2000, alterou a dinâmica política e institucional, permitindo que, até muito recentemente, as mudanças que permaneciam bloqueadas começassem, a partir de então, a ser efetivadas diante da menor capacidade de exercício de tais vetos.