Healthy or Sick? Coevolution of Health Care and Public Health in a Comparative Perspective
Tuohy documents a mosaic pattern of policy change in two very different political systems: the US, where the Obama administration’s piecemeal but simultaneous and rapidly enacted policy changes could be expected, and the UK, where this pattern emerged from an unprecedented Conservative‒ Liberal Democratic coalition government.
Abstract
power struggles within deeply divided executives. These internal rivalries undermined their sense of control over the agenda but, more importantly, pushed both governments to delay reforms, well past their windows of opportunity. The single case of “blueprint” reform occurred in the Netherlands, made possible by a stable, “centrist coalition-government tradition, consensual political culture, and cooperative networks of intermediary associations” (p. 373). Two successive coalition governments led by the Christian Democratic Appeal party were able to build a broad and stable consensus around a comprehensive plan to overhaul the health insurance system. This consensus endured through two decades of partisan transitions, piecemeal and episodic enactment, and drawn-out implementation. Finally, Tuohy documents a mosaic pattern of policy change in two very different political systems: the US, where the Obama administration’s piecemeal, but simultaneous and rapidly enacted policy changes could be expected, and the UK, where this pattern emerged from an unprecedented Conservative‒ Liberal Democratic coalition government. In both cases, policy makers realized they faced a narrow window of opportunity before their shaky coalitions would collapse, necessitating an amalgam of concessions, compromises, and opportunistic initiatives that could be enacted within a foreshortened timeframe. Tuohy concludes her analysis by outlining the role of “institutional entrepreneurs” – both products and agents of the reforms – who influenced the substance of health policy in each country toward its own unique logic of state‒market hybridization. She demonstrates the significant impact that decisions about scale and pace have on both the content and outcomes of policy change. Where the framework and analysis fall short is in exploring the mental models that underpin the otherwise highly contextualized and historically embedded decisions of policy actors. Policy makers’ choices are undertheorized, and at times seem overdetermined by institutionalized vetoes and decision pathways. There are few patterns or explanations that emerge from the comparative analysis of cases that explore or explain actors’motivations. So, for instance, what impels policy makers to seek large-scale change in the first place? How do actors decide, and build consensus under conditions of fragmented control, to enact large-scale versus incremental change? How and which factors are weighed in calculating potential future losses or gains in order to make decisions about pace? It’s important to note, however, that these questions emerge from and are crystallized because of the necessary order Tuohy’s framework imposes on an otherwise messy, complex, and almost impenetrable web of decisions that constitute policy change. This brief summary outlines the framework Tuohy develops, but fails to do justice to the exhaustive, richly detailed analysis she provides of seven decades of health policy development across four disparate nations. Her carefully researched analysis makes a compelling case for a more nuanced understanding of policy change, beyond a dichotomized typology and an institutionally patterned calculus, that accounts for the fundamental agency of policy actors. The framework, constructed around her novel axis of scale and pace, usefully categorizes and describes the strategic choices of actors and the ensuing patterns of policy change. Through her extensive research on health systems, Tuohy develops a model of strategic choice that can be fruitfully applied across a wide range of issue areas.