Hyper‐stasis as opposed to hyper‐activism: the politics of health policy in the USA set against England

SUMMARY This paper considers health policy‐making in the USA with England as comparator. It contrasts policy inertia in US healthcare despite crisis with hyper‐activity in perpetual ‘reform’ in England despite absence of crisis in the NHS. It does so from the standpoint of political science and political economy. I suggest that ‘path‐dependency’, the view that past policy constrains future policy, lacks explanatory power and that wider and deeper explanations must be sought. The USA's apparent path dependency is in fact a story of political economy and power, buttressed by institutions. England's apparent lack of path‐dependency in promulgating NHS reform is in fact a story of executive hyper‐activism which is oblivious to how implementation will obviate its prescriptions. This failure of ‘reform’ in the NHS is not a symptom of concealed path‐dependency but a sign of pragmatism by those charged with implementation. In the USA, the durability of its various systems of healthcare is by contrast a sign of pragmatism not being adequate to achieve health sector reform. In the USA, a weak state is unable to manage healthcare reform which would actually benefit US capitalism as a whole. In the UK, a strong state has created and developed the NHS to the benefit of capital through the economical provision of healthcare to the workforce. Such an ‘investment state’ is a testimony to the continuing validity of the neo‐Marxist argument that social investment and social expenses are an important and functional component of the capitalist state. Copyright © 2013 John Wiley & Sons, Ltd.