1 The London School of Economics and Political Science The Political Consequences of Regulatory Reforms: Drug Rationing Policies in England and France Takuya Onoda A thesis submitted to the Department of Government of the London School of Economics for the degree of Doctor of Philosophy, London, December 2018 2 Declaration I certify that the thesis I have presented for examination for the MPhil/PhD degree of the London School of Economics and Political Science is solely my own work other than where I have clearly indicated that it is the work of others (in which case the extent of any work carried out jointly by me and any other person is clearly identified in it). The copyright of this thesis rests with the author. Quotation from it is permitted, provided that full acknowledgement is made. This thesis may not be reproduced without my prior written consent. I warrant that this authorisation does not, to the best of my belief, infringe the rights of any third party. I declare that my thesis consists of 99,268 words. Statement of use of third party for editorial help I can confirm that my thesis was copy edited for conventions of language, spelling and grammar by Jeremy Grove. 3 Abstract The past few decades have seen the proliferation of regulatory agencies, expert committees, and other “non-majoritarian” institutions in Europe. Scholars tend to assume that once created, policies corresponding to these institutions persist, disrupting the existing governance structure. This thesis instead argues that policy continuity following the creation of agencies depends on the locus of regulatory decisions. Specifically, it proposes that the extent to which elected politicians are excluded from the decision-making, i.e. their level of “political insulation”, affects policy continuity. Where elected politicians are excluded from the decision-making, this enables unpopular policy choices. But such choices, once made, generate a greater counter-mobilisation, undermining policy continuity over time. By contrast, where elected politicians have the final say on decisions, they can prevent unpopular policy choices from being taken, which contributes to policy continuity. To illustrate these mechanisms, this thesis takes restricting the funding of pharmaceutical products by the healthcare system as a case of an unpopular regulatory policy and compares its development in England and France. Both countries established regulatory agencies tasked to assess the benefits of drugs for funding decisions, but the nations subsequently followed divergent trajectories. In England, high political insulation enabled policy choices that otherwise would have been too politically costly. Yet these choices, over time, led to a greater counter-mobilisation through public and electoral arenas, resulting in a partial policy reversal. By contrast, in France, low political insulation allowed ministers to choose not to follow the agency’s outputs when they considered them too politically costly; ministers also prevented rule changes that might have made more politically-costly outputs possible. The findings highlight the endogenous drivers of post-regulatory reform policy development. Contrary to the linear trajectory, where “depoliticised” agencies reinforce themselves, the thesis suggests that under certain conditions, the policies that accompany regulatory agencies can undermine themselves by becoming a source of greater politicisation. 4 Acknowledgements First, I thank my supervisor Mark Thatcher for his guidance throughout. His rigorous approach has constantly encouraged me to push my boundaries, while his wise counsel has helped me surmount many pitfalls and hurdles that I encountered during the PhD. Especially on the latter, my advisor Jonathan Hopkin has also been generous in his feedback and encouragement, to which I am grateful. Many other faculty members of the Department of Government, and the broader intellectual community of LSE, have helped me move this project forward and grow as a scholar. I especially thank Cathy Boone, David Soskice, Martin Lodge, and Ed Page for engaging with me in inspiring conversations and for giving me examples through their scholarly enterprises. I am indebted to Kai Spiekermann, who, as the Department’s Doctoral Programme Director, has provided me with institutional – and at times moral – support when they were most needed. Pharmaceutical policy is a complex subject, and I have greatly benefited from the support of those who specialise in this policy sector. I am deeply grateful to the people who agreed to be interviewed for this project. They took time out of busy schedules to share their views and experiences with me. From conversations with them I learned a lot about the subject’s complexity as well as its richness. In navigating the world of pharmaceutical policy I am indebted to scholars around LSE Health, especially Panos Kanavos and John Wright, who helped me identify potential informants and explained aspects of the policy sector to me. For my research in France I enjoyed a great deal of help and support, without which the project would not have been possible. At the Centre de Sociologie des Organisations (CSO) of Sciences Po, which became my intellectual home during my stay in Paris, I especially would like to thank Olivier Borraz, who was generous in his institutional support, and Etienne Nouguez, who, as a fellow scholar on pharmaceutical policy, shared many insights about it and was kind in assisting several aspects of my research. I also thank many other academics who took time to help me understand the dynamics of the sector and offered me suggestions about the project, including Isabelle Durand-Zaleski, Boris Hauray, Catherine Le Galès, Jérôme Greffion, Patrick Castel, Henri Bergeron, and Daniel Benamouzig. I wish to thank Jared Finnegan and Eva Ruffing, who have read parts of the manuscript and offered me valuable comments. I also thank feedbacks I have received from participants at 5 various conferences and workshops at LSE, the European Consortium for Political Research, and the Council for European Studies. Conversations with Hanan Haber, Eva Heims, Flavia Donadelli, and Elena Pupaza have clarified my thinking and helped me tackle different issues in the project. I thank Antoine Louette for answering questions about word choices for translation of some French terms. I am grateful for financial support from LSE, the Konosuke Matsushita Memorial Foundation, and the Kikawada Foundation. Friends and colleagues at LSE have been instrumental in the completion of this PhD, not only intellectually but also personally. Special thanks to Nimrod Kovner and Flavia Donadelli, whose friendship have been crucial throughout. Many thanks to fellow PhD students in the Department of Government, who have helped me go through challenges at different stages of the PhD and have enriched my life in London, including, among many others, Meor Alif, Anastasia Nosova, Izabela Corrêa, Ricardas Juskevicius, Elena Pupaza, Selina Hofstetter, Elisa Cencig, Jan Stuckatz, Kaveh Pourvand, Giulio Lisi, Paola Romero, Antoine Louette, Ariel Perkins, Max Kiefel, Chris Sampson, Bernardo Rangoni, Moritz Schmoll, Ellie Knott, Laura Robbins-Wright, and Marta Wojciechowska. Before I embarked on this project in London, my undergraduate and graduate education in Tokyo had profound impacts on shaping my aspirations as a political scientist. I thank my teachers whom I met during my days at the University of Tokyo, especially Kenji Hirashima, Yohei Nakayama, and Ryosuke Amiya-Nakada, who introduced me to the world of research on European politics and have continued to be generous in their encouragement and support; Masahiko Aoki, whose tireless intellectual curiosity is much missed; and Hiroshi Takayama, who gave me an earlier opportunity to immerse myself in world politics. Finally, I thank my mother, my sister, and my late father, who have supported this journey in countless ways. 6 Table of Contents Abstract .................................................................................................................................... 3 Acknowledgements .................................................................................................................. 4 Table of Contents ..................................................................................................................... 6 List of Figures and Tables ........................................................................................................ 7 List of Abbreviations ............................................................................................................... 8 Introduction ............................................................................................................................ 10 Chapter 1 Studying political dynamics in the post-reform period: An analytical framework ............................................................................................................................ 24 Chapter 2 Experts rule: The emergence of high political insulation in England, 1989-1999 . ............................................................................................................................ 58 Chapter 3 Ministers decide: The emergence of low political insulation in France, 1990-2004 ............................................................................................................................. 87 Chapter 4 The regulatory state under pressure: England, 1999-2010 ..............................