Healthcare Reform: Can Citizens Decide?

Oliver Taylor | Europe and Eurasia Fellow

Image sourced from Markus Spiske via Unsplash

In 2016, ninety-nine Irish citizens gathered in Dublin to examine whether Ireland’s constitution should continue to prohibit abortion. Over several months they heard from clinicians, legal scholars, ethicists, and advocacy groups representing opposing positions. The recommendations helped shape the 2018 referendum that repealed the Eighth Amendment, transforming reproductive healthcare policy and demonstrating that structured public reasoning could shift debates long considered politically immovable.

Across Europe, the tension between the scale of healthcare reform required and the political legitimacy needed to deliver it is becoming structural. Citizens’ assemblies are emerging as one answer: structured deliberative processes that build political legitimacy not by removing difficult trade-offs, but by preparing societies to confront them. Healthcare spending now averages roughly 10–12 per cent of GDP across Western Europe according to OECD Health at a Glance reports, driven by ageing populations, workforce shortages, and rising treatment costs.

By 2050, the proportion of Europeans over 65 is projected to approach 30 per cent in several countries, forcing governments to confront the potential trade-offs between maintaining universal access to healthcare, controlling spiralling pharmaceutical and workforce expenditure, and redesigning services. Healthcare is where fiscal sustainability collides most visibly with expectations of social protection, and where even modest reforms can trigger fears about fairness or access. The challenge is therefore not simply designing reform, but building the legitimacy required to sustain it.

Across Europe, the constraint on healthcare reform is increasingly a matter for successful political agendas: not what governments should do, but what electorates will accept before crisis forces change. Germany’s hospital consolidation reforms—broadly supported by clinicians and designed to address chronic overcapacity—stalled repeatedly against regional political resistance. It is a pattern repeated across the continent: the technical solutions exist, but the political consent does not.

From Consultation to Deliberation

Deliberative democracy involves representative groups of citizens, usually selected through civic lottery, examining complex policy questions after hearing structured evidence from experts and stakeholders. I was reminded of the shift from traditional consultation processes to deliberative forums during a recent discussion with Dr Adele Webb from the Centre for Deliberative Democracy and Global Governance, where it was discussed how citizens’ assemblies are increasingly being used not simply to consult the public, but to prepare the political ground on which difficult decisions must eventually stand.

Unlike traditional consultations, which often measure existing opinion, deliberative forums examine how views change once citizens engage with constraints and trade-offs faced by decision-makers. Informed discussions can instead be utilised to demonstrate how difficult trade-offs can be understood rather than imposed.

This shift in approach addresses a growing dilemma for European governments. Many healthcare reforms fail not because policymakers lack solutions, but because governments lack the political space to implement them. Voters may support healthcare improvement in principle while resisting specific changes affecting local hospitals or services. Deliberative processes attempt to narrow this gap by exposing citizens to the same constraints policymakers face, helping prepare societies for reforms that might otherwise remain politically impossible.

When Healthcare Reform Becomes Political Risk

Across Europe, healthcare reform operates within a broader environment of political fragmentation and declining institutional trust. Eurobarometer surveys consistently show political parties are among the least trusted institutions in the European Union, and electoral volatility has narrowed the margins within which structural reform can occur.

This helps explain why even efficiency-enhancing reforms encounter resistance. Electoral risk is immediate while the benefits of reform are delayed, making the political cost of action appear higher than the policy cost of inaction. Deliberative processes cannot remove these pressures, but they may allow governments to demonstrate fairness not only in what decisions are made, but in how they are reached.

France’s Citizens’ Convention on Climate demonstrated how deliberative processes can examine policy questions involving environmental exposure, public health, and economic transition. Its 149 proposals directly informed France’s 2021 Climate and Resilience Law, demonstrating that citizens engage seriously with complex trade-offs when given the structured evidence to do so. In the United Kingdom, citizens’ panels linked to National Health Service planning have informed elective care priorities, contributing to decisions that balanced access with workforce constraints.

The Culture Shift Governments Quietly Need

Participants in deliberative forums often report changes not only in their policy views but in how they approach disagreement. Exposure to competing evidence and structured dialogue can cultivate democratic soft skills: the capacity to listen across difference, weigh uncertainty, and revise positions—precisely the habits healthcare debates tend to erode.

These effects are difficult to measure, yet they may prove politically significant. Democratic systems depend not only on institutions, but on habits of reasoning that allow disagreement to remain productive. Deliberative processes may therefore contribute not only to better policy design but to the democratic resilience required when governing becomes even more complex.

Governing Complexity

None of this suggests deliberative democracy is a cure-all. Citizens’ assemblies cannot substitute for elected government, and processes that governments fail to act on risk becoming exercises in consultation theatre. Ireland’s experience nevertheless demonstrated something important: citizen deliberation can help move entrenched healthcare debates from political stalemate toward actionable consensus when governments engage seriously with the outcomes.

The deeper lesson may be less about any single reform than about governing complexity itself. In healthcare policy, where evidence alone cannot resolve disagreements about values, costs, or fairness, how governments build consent may matter as much as what they decide. Europe’s deliberative experiments suggest a simple lesson: difficult healthcare reform depends not only on good policy, but on whether governments and societies are willing to confront trade-offs together.

Ollie Taylor is the 2026 Europe and Eurasia Fellow for Young Australians in International Affairs (YAIA). He studies Commerce and Biomedical Science at the University of Queensland and has lived across Europe, Asia, and Australia. As a 2025 Westpac Asian Exchange Scholar, he studied cancer biology at the National University of Singapore, undertook Mandarin language training while working in Singapore, and led healthcare-promotion volunteer teams in rural Thailand through Challenges Abroad. He has also backpacked widely across Asia to deepen his regional literacy and cross-cultural understanding.

Ollie previously studied International Relations at the London School of Economics, informing his interest in global governance, health resilience, and cross-regional cooperation.

As YAIA’s Europe and Eurasia Fellow, he is committed to strengthening Australia’s engagement with the region and advancing more resilient health systems in less-economically developed rural communities, where development and security challenges intersect most sharply.

Disclaimer: The views and opinions expressed in this article are those of the author, and do not necessarily reflect the views and opinions of Young Australians in International Affairs. AI tools were used by this author for grammar checks but all content is original, and no plagiarism has been used in the preparation of this article.