Linos Book Symposium: Comments by Larry Helfer

[Larry Helfer is the Harry R. Chadwick, Sr. Professor of Law Professor of Law at Duke University School of Law]

Katerina Linos has written an audacious and analytically rigorous study of how health and family policies spread over time across industrialized countries.  She deftly synthesizes a broad range of qualitative and quantitative research methods into a brilliantly-conceived research design that analyzes the mechanisms by which such policies disperse across borders.  The book’s core findings—that foreign and international models influence domestic policy adoption via politicians’ appeals to skeptical voters who view such models favorably—are highly counterintuitive.  The findings are at odds with the existing literature on policy diffusion, which identifies networks of experts and elites as the primary transmission mechanisms.  They are also contrary to the conventional wisdom that resistance to foreign and international policies is especially strong in the United States, where voters are thought to be unaware of such exemplars or mistrustful of those they have encountered.

My comments focus on chapters 3 and 4 of the book, which consider, respectively, how Americans view foreign models and how national health services have diffused across OECD member states.  Linos labels the first question as a “hard test case” for her theory (p.36), for the reasons just noted.  To search for evidence that U.S. voters and politicians are swayed by foreign policies, she conducts public opinion experiments and codes Congressional debates leading to the adoption of the 2010 Affordable Care Act and the 1993 Family Medical Leave Act.  The experiments suggest that Americans are much more likely to favor publicly-funded health insurance and maternity leave if such policies have previously been adopted by most Western countries or endorsed by the United Nations.  Linos also finds that members of Congress reference the health and family policies of rich, proximate and familiar nations rather than countries that experts view as the most relevant to the United States.

Chapter 4 makes the more modest claim that the national health systems (NHS) of foreign countries with the characteristics identified above (and, to a much lesser degree, nonbinding international norms endorsing universal primary healthcare) explain the spread of health policies among industrialized countries.  Here Linos builds upon an existing literature that identifies facilitating conditions for the adoption of NHS, but that has yet to explain the timing and geographic spread of those policies.  Chapter 4’s conclusions, although more nuanced than those of chapter 3, provide additional evidence to support Linos’ theory of democratic diffusion.

I have two sets of comments and questions about Linos’ arguments and findings in these chapters.  The first relates to when foreign examples influence the policy deliberation and adoption process.  The examples Linos considers reveal the influence of foreign models once lawmakers are actively considering reform proposals.  But what relevance, if any, do such models have on agenda setting?  Attempts to enact comprehensive healthcare reform in the United States provide an apt illustration.  Linos notes that Congress has considered such reforms at least six times in the 20th century, and that it finally adopted a national healthcare scheme in 2010 “long after other rich Western countries had done so.” (p.39)  Yet her analysis does not consider (other than a passing statement on p.57 that “foreign models are most relevant in the early, agenda setting stages of the policy process”) whether healthcare policies adopted by other nations or endorsed by international organizations help or hinder lawmakers in placing reforms on the legislative agenda in the first instance.  To be sure, evidence that foreign models are influential in agenda setting is not necessary for Linos’ democratic diffusion theory to hold true.  But such evidence would help to identify with greater precision the conditions under which non-local models can help or hinder efforts to jump start the policy reform process.

My second comment concerns a different timing issue—the event that first triggers policy diffusion across borders.  Linos does an excellent job of explaining why voters and politicians emulate particular non-domestic precedents once the transborder policy diffusion process is underway.  But she gives insufficient attention to how the diffusion process begins.  For some issues (e.g. maternity leave and the ILO) international organizations are the innovators.  For others, a single country (e.g. the United Kingdom’s adoption of a NHS in the mid-1940s) is the trendsetter and international bodies follow much later with vague and nonbinding norms that have only modest influence at best (e.g. the WHO’s 1978 Alma-Ata Declaration).  It would be useful to consider whether diffusion patterns vary depending on which actor initiates the policy reform process.  The impact on emulating countries of the interaction between foreign and international models also needs greater attention.  For example, Linos’ public opinion experiments suggest that American voters give more weight to endorsements by the U.N. than to policies adopted by nations similar to the U.S.  Yet in the two real world examples she analyzes—healthcare reform and family medical leave—it is the policies of foreign countries, not those endorsed by international organizations, that capture the attention of voters and legislators.

Scholars interested in the micro-foundations of transborder policy diffusion might address these or similar issues in future work.  Their relative absence from Linos’ book in no way detracts from what is, by any measure, an insightful, sophisticated, and ultimately highly persuasive study.