ABSTRACT
While often presented as an agenda of realizing efficiency gains, austerity – as we know after a generation of such policies – is at its core a challenge to universalism. This chapter shows that one of the victims of austerity is diversity in health system governance. The great variety of power-sharing arrangements and dispersed authority in regulating and administering healthcare that has characterized the organizational landscape in European countries has given way to a more important role of central governments – specifically, in assuming control and responsibility for healthcare delivery, notwithstanding their public pronouncements of decentralization and market autonomy. Once they have extended universal coverage to a population, governments are trapped in the tradeoff between quality universal healthcare and every other public expenditure or tax cut. This distributional politics drives central governments deeper and deeper into the micro-management of healthcare systems. With health policy closely intertwined with the fiscal policies of individual member-states, the scope of European Union health politics has long remained limited. It took the major disruption of the COVID-19 pandemic, and concomitant enormous expansion of public health and civil protection budgets, to establish the Union as an active agent of intervention in health policy.
