The electoral politics and the evolution of complex healthcare systems

The complexity of contemporary healthcare systems is a consequence of public policy decisions made over many decades. In 1883, Germany adopted a national healthcare insurance program under which employers and employees contributed to health treatment and income security funds. Similar systems were adopted by many other OECD countries during the next half century. These insurance-based programs were revised many times in the decades that followed. Because of this, each nation’s system exhibits some path dependence and inertia, although the systems are sufficiently malleable that in the long run each nation’s healthcare system can take virtually any form that is fiscally sustainable. This paper explores the extent to which electoral pressures can account for the path of reform in the late 20th century.