Contested Regulators: Politicizing Drug Rationing in Advanced Democracies

Under what conditions do policies by unelected expert bodies get politicized and prove unstable and under what conditions do they prove stable? The question is fundamental to the legitimacy of democratic governance. The last few decades have seen the proliferation of delegated, non-majoritarian institutions, such as independent regulators and central banks and supranational institutions, across the world. Both proponents and critics of such institutions have tended to assume that the creation of these delegated bodies indicates the process of "depoliticization". Recent scholars, however, have increasingly noted counter-mobilization and open contestations around policymaking by unelected bodies – an observation that calls the assumed linkage between delegation and depoliticisation into question. In this paper I problematize the relations between (de)politicization and argue that, rather than reinforcing the depoliticized mode of governance, the very functioning of unelected bodies can lead to politicization. I develop an analytical framework for better understanding the links between politicization, depoliticization, and the delegation of powers to non-majoritarian institutions; the framework highlights the role of varying decision-making structures created by the initial delegating reform in shaping the subsequent politicization and policy (in)stability. I also provide a typology of strategies that incumbent regulatory policymakers deploy to cope with counter-mobilization and identify the limitations of the strategies and how they are related to subsequent policy and institutional change. The paper illustrates these arguments through a comparative-historical analysis of drug rationing policies—policies for restricting the provision of pharmaceutical products through the health care system. The domain provides an excellent window onto the political struggles over the evolution of non-majoritarian institutions, given both its strong functional demands for expert-driven, evidence-based policymaking, on the one hand, and its deeply political consequences due to loss-imposing decisions, on the other. I trace the evolution of drug rationing policies in three major advanced economies with different regulatory decision-making structure – England, France, and Japan – since the late 1980s, the period when debates over reforming regulatory institutions began in earnest. The three main country cases have shared several broad characteristics as well as trends that have put them under pressures around funding healthcare, including technological advances and demographic change; they, however, differ in the regulatory decision-making structures after the institutional reforms. Combining comparative case studies with process tracing, I uncover how the different regulatory decision-making structures affected politicization, and how politicization, in turn, have shaped policy development. My findings shed light on the forces behind political struggles after the delegation reform and have implications for both the legitimacy and sustainability of the regulatory state and its relations with democratic governance.