POLITICAL PARTIES AND POLICY REFORM: EXPANSION OF HEALTHCARE IN LATIN AMERICA Zoila Ponce de Leon A dissertation submitted to the faculty at the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Department of Political Science of the University of North Carolina at Chapel Hill. Chapel Hill 2018 Approved by: Evelyne Huber Frank R. Baumgartner Jonathan Hartlyn Cecilia Martínez-Gallardo John D. Stephens © 2018 Zoila Ponce de Leon ALL RIGHTS RESERVED ii ABSTRACT Zoila Ponce de Leon: Political Parties and Policy Reform: Expansion of Healthcare in Latin America (Under the direction of Evelyne Huber) Over the last decades, Latin American countries have attempted to expand access to healthcare and reform a system that discriminates based on the socioeconomic status of their citizens. Although previous research has posed that programmatic parties are important for policy quality, it has not shown the mechanisms through which programmatic parties can affect policy. Existing literature has also focused on the responsibility of strong left-wing parties for the expansion of social benefits, overlooking the development of reforms under right-wing governments. This study compares three processes of healthcare reform: the Chilean AUGE (Universal Access with Explicit Guarantees), enacted in the context of programmatic parties and a left-wing coalition in power, the Mexican Seguro Popular, approved in the context of programmatic parties and a right-wing party in power, and the Peruvian AUS (Universal Health Insurance), adopted in the context of non-programmatic parties and a right-wing party in power. I argue that the programmatic commitments of parties, only present when the core values that unite party leaders relate to a policy issue, affect the quality of legislation. Reforms can follow a partisan path in which parties with values closely tied to the policy issue shape a reform’s specifications regarding implementation and funding. Reforms can also follow a non- partisan path in which parties disengaged from the definition of specifications allow technocrats without partisan ties to dominate the policymaking process. Given the lack of commitment from iii the main political actors, this leads to a policy that is poorly designed for effective implementation. Both paths can lead to reforms that increase formal coverage and even funding of the health sector. The key difference is in the feasibility of ensuring effective access to healthcare and the sustainability of funding. This study is based on 12 months of extensive field research in Chile, Mexico, and Peru, during which I conducted over 150 in-depth interviews with political elites, technocrats, and leaders of interest groups, accessed archives from the Legislatures and the Executives, and collected quantitative measures of the implementation of the reforms. iv To my parents. v ACKNOWLEDGEMENTS! Several people have provided guidance and support throughout my graduate studies at UNC, making it possible to write this dissertation. My advisor, Evelyne Huber, has not only provided firm guidance at every stage of my path to become an academic, but has also incited in me enthusiasm and passion for the study of comparative politics and Latin America. Evi always went the extra mile, providing support for the many challenges both academic and personal that are encountered during the Ph.D. process, including returning detailed feedback on my work with unnerving speed. Evi is able to listen to a muddle of ideas and questions and sort and repeat the ideas back to you with incredible and succinct clarity. After a meeting with Evi, I always had a renewed enthusiasm for my research. I have been incredibly fortunate to benefit from Evi’s mentoring and she has taught me the value and need for caring and engaged mentors like her. I am also extremely grateful to the rest of my dissertation committee. Frank Baumgartner encouraged me to pursue my interest in the politics of policymaking and pushed me to clarify what at the time were very broad and unclear questions about policy reforms. Jonathan Hartlyn provided detailed advice on my research and never hesitated to push me to think about the broader theoretical implications of my work. Cecilia Martínez-Gallardo’s insightful comments made the arguments and empirics presented in this dissertation more coherent and clear. John Stephens was always there to ask the hard questions while showing enthusiasm for my research at the same time. All my committee members have been incredibly generous with their time and I will be always thankful for the careful guidance they have provided. I would also like to thank Tom Carsey and Lars Shoultz at UNC, who provided intellectual vi guidance, encouragement, and kindness from day one. I owe a great debt to them. Former students Santiago Anria, Sara Niedzwiecki, and Ali Stoyan were not only sources of inspiration and figures to look up to, but also friends. I am also very grateful to my students at UNC during these past years, which made the lonely journey of writing a dissertation a lot more enjoyable. For their close friendship during graduate school, I would like to thank Katie Aha, Menevis Cilizoglu, Federico Fuchs, Gabriele Magni, Deniz Ozturk, Vicky Paniagua, and Beatriz Rey. Intellectually stimulating conversations with them have helped me to grow academically, and their willingness to let loose and have fun helped me to stay sane during these years. Outside UNC, I am particularly thankful to Eduardo Dargent and Steve Levitsky; their generosity showed no limits and their support has enhanced my work at different points of graduate school and even before it began. Ryan Carlin, Candelaria Garay, Christina Ewig, Herbert Kitschelt, Jenny Pribble, Karen Remmer, and Elizabeth Zechmeister were always willing to provide feedback as well advice on how to navigate academia. I am also grateful to Henry Dietz and Martín Tanaka, who encouraged and inspired me to pursue a doctoral degree. The research and writing of this dissertation would not have been possible without the generous support of different organizations. The American Political Science Association Centennial Center through the Fund for Latino Scholarship, as well as a Tinker Foundation Pre- dissertation Field Research Grant from the Institute for the Study of the Americas (ISA) at UNC enabled preliminary field research for this dissertation. A Mellon Dissertation Fellowship from ISA and an Off-Campus Dissertation Research Fellowship granted by the Graduate School at UNC made it possible to conduct research in Peru, Chile, and Mexico. I was able to focus entirely on writing this dissertation during the 2017-2018 years thanks to the Dissertation Completion Fellowship from the Graduate School at UNC. Several Thomas M. Uhlman vii Research Awards and a Matthew J. Burbank Research Fellowship allowed high levels of productivity during the summers. A large number of politicians, technocrats, activists, academics, and journalists helped during my field research in Peru, Chile and Mexico. For the generosity of every single one of them, I am extremely thankful. In Peru, I am especially grateful to Eduardo Dargent at Pontificia Universidad Católica del Perú and Margarita Petrera at the Consorcio de Investigación Económica y Social (CIES). In Chile, Gabriel Bastías at Pontificia Universidad Católica de Chile, Mireya Dávila at Universidad de Chile, Claudio Fuentes at Universidad Diego Portales, and Juan Pablo Luna at Pontificia Universidad Católica de Chile were incredibly helpful. In Mexico, Allyson Benton and Joy Langston at Centro de Investigación y Docencia Económicas (CIDE), Octavio Gómez at the Instituto Nacional de Salud Pública (INSP), and Olivia López at Universdidad Autónoma Metropolitana (UAM) were always willing to help me. I am eternally grateful to my family and friends. My parents, Verónica Seijas and Juan Ponce de León have been incredibly supportive, patient and loving. I will always look up to them, for their commitment and determination. My nieces and nephews might have no idea of how important they have been, but each smile, hug, and loving word that came from them re- energized me to continue with this dissertation. My best friend, Milagros Meza, regardless of the distance, has always been with me. Luke Chanarin, my husband, has been more significant for the process of writing and culmination of this dissertation than he could ever imagine. Always full of love, wisdom, intellectual curiosity, patience (a lot of patience), and wittiness, Luke never stopped supporting this project as well as every other goal I had set for myself. Moving to a different continent is just one of the many hardships he was willing to go through. I am truly humbled and hugely grateful for his thoughtfulness and love. viii TABLE OF CONTENTS LIST OF TABLES ........................................................................................................................ xii LIST OF FIGURES ..................................................................................................................... xiii LIST OF ABBREVIATIONS ...................................................................................................... xiv CHAPTER 1: INTRODUCTION ................................................................................................... 1 Theoretical Relevance ................................................................................................................. 3