Politics in the Shadows: Coalition-Building and Long-Term Care Reform in Southern Europe

Long-term care (LTC) policies for dependent older people provide a strategic lens through which to examine patterns of change and inertia in Southern European welfare states after a decade marked by multiple crises. Situated at the intersection of healthcare and social assistance, LTC crystallises enduring political tensions—between universalism and residualism, family responsibility and public intervention, and centralisation and territorial autonomy—while remaining a low-salience and highly technical policy domain. Despite facing similar demographic pressures and sharing familistic welfare legacies, Spain, Portugal, and Italy have pursued markedly different LTC reform trajectories between 2000 and 2024. This paper asks how processes of political change unfold in low-visibility policy arenas in the post-crisis context, and how coalitions of political and social actors emerge, stabilise, or fragment over time. Drawing on the concept of political exchange (Natili 2019), the paper conceptualises LTC reform as a negotiated process through which functional pressures and social demands are translated into institutionally viable solutions via compensation, sequencing, and strategic compromise. This framework foregrounds politics: the construction of alliances and oppositions, the management of conflict across sectoral and territorial cleavages, and the shifting balance between cooperation and contestation as crises open—and close—windows of opportunity. The comparative analysis identifies three distinct puzzling patterns. In Spain, the Ley de Dependencia (2006) resulted from a broad and politically salient coalition linking central government, Autonomous Communities, trade unions, civil-society organisations, and service providers. Through explicit political exchange, this coalition reframed dependency as a new social risk and institutionalised LTC as a subjective right, while accommodating market- and family-oriented claims. In Portugal, the Rede Nacional de Cuidados Continuados Integrados (2006) emerged from a more technocratic and corporatist bargain among ministries, health professionals, and faith-based non-profit providers, strengthening coordination and continuity of care while largely preserving existing distributive arrangements. Italy represents a contrasting post-crisis trajectory: despite intense ideational learning and unprecedented mobilisation by a purpose-driven social coalition during the pandemic, the reforms adopted through Law 33/2023 and Legislative Decree 29/2024—under the constraints of the EU Recovery and Resilience Plan—produced a clearer institutional framework but limited structural change, leaving the centrality of cash transfers and family-based care largely intact. Across cases, the analysis shows that crisis-driven openings do not automatically translate into durable transformation. Coalition-building capacity and government strategy—particularly the ability to institutionalise negotiation arenas and to link LTC to broader political agendas—prove decisive. Low public salience, high technical complexity, and fragmented interests among familialist, market, and public actors systematically shape the strategies of allies and opponents, helping to explain why Southern Europe remains a crucial site for observing both innovation and inertia in post-crisis politics. Methodologically, the paper adopts a historical-institutionalist and process-tracing approach, combining documentary analysis with 61 elite semi-structured interviews conducted between 2023 and 2025 across the three countries. By unpacking the political mechanisms connecting coalition dynamics to reform outcomes, the paper contributes to broader debates on change in Southern Europe, showing how post-crisis reform trajectories depend less on functional pressures alone than on the politics of coalition-building in low-salience policy domains.