Creating Legitimacy in Hard Times – How Governments Justify Controversial Health Care Reforms

Looking at health care policymaking in four European countries (UK, France, Hungary and Ireland) after 2008, this paper explores the narratives that allowed governments to secure legitimacy for controversial policy reforms. The paper is guided by the question of how governments are able to avoid backlash from professional communities and the general public when implementing retrenchment measures in sensitive policy domains, such as health care. Health care is an area where policy outcomes potentially affect every citizen, therefore it is difficult for governments to isolate or compensate the losers of reforms. At the same time, in health care the links between government decisions and material outcomes are not always directly observable to individuals. In consequence, legitimating narratives explaining this link have particular importance. Finally, health policy making relies heavily on expert knowledge, also in the sense that it is health care professionals who implement reforms on the ground and can transmit government narratives to citizens. Our main proposition is that due to these structural features of health care, from input, output and throughput legitimacy, the fate of reforms will be first and foremost decided by the discourses around throughput legitimacy. To support this claim, the paper brings evidence from policy documents, legislation and public speeches in health policymaking in four European countries that have different health care systems. The paper contributes to the discursive institutionalist perspective on welfare state reforms and to the literature on welfare state retrenchment.