How ought we to understand complex policy formulation in a systematic and rigorous way? Can it only be understood in retrospect as an outcome that occurred due to specific variables that materialized at particular times for fortuitous reasons? Or can we construct analytical schema to help us understand policy change across time and geography as phenomena that respond to common drivers in a more logical and constant manner? Health policy, in particular, has increasingly become the subject of political analysis, driven by its importance to voters and the sheer cost of funding health care in modern polities. Yet it is not an easy field to grasp, given its technical complexity, local variation, and the often opaque political dynamics between stakeholders.
Two Canadian political scientists have new books focusing on health care. Both are based at the University of Toronto, and both have made valuable contributions to the literature on health policy over the past several decades. It is intriguing, then, that these books are so dissimilar. They are two quite distinct volumes, with very distinct objectives, written for considerably different audiences.
In Treating Health Care, Raisa Deber has written a short primer on health care for those with no background in health policy. It is an accurate and accessible account of how health care systems (mostly with reference to Canada) work in general terms. Care is taken to define terminology with precision: the entire first chapter comprises an explanation of basic terms (“policy”, “institutions”, “health care”, etc.), while the second chapter elucidates the component parts of health care systems (“primary health care”, “long-term care”, “regulated health professions”, etc.). It is an excellent book for those who desire a brief and uncomplicated account of how things work, without the distraction of a theoretical layer attempting to explain why it is that they take the shape that they do. This is not a criticism: those wanting to assemble air conditioners do not want to wade through disquisitions on thermodynamics to do so; and those wanting a basic understanding of health care should be spared the deep dive into independent variables and confounders.
Weighing in at over 700 pages, Carolyn Hughes Tuohy's Remaking Policy is a rich, complex and intellectually ambitious analysis of cross-national health care reform. While digesting the entire volume requires a certain level of dedication, the book comprises three artfully interwoven but discrete intellectual endeavours that could be tackled separately. The first is the development of a heuristic framework for analyzing health care reform (parts 1 and 5); the second is a detailed narrative of how, precisely, attempts at health care reform played out in four jurisdictions at particular times (parts 2 and 3); and the third is a provocative argument explaining substantive health policy change through the medium of “institutional entrepreneurs” (part 4).
Tuohy's explanatory model goes beyond a focus on reforms themselves to examine the political context within which these reforms are formulated. She situates her theoretical framework within the debate over punctuated equilibrium and incrementalism as vehicles of policy change, with a particular interest in “bringing agency back in”. This she does by examining why policy makers make the choices they do when windows of opportunity open to them. Why are some attempts at seizing this window of opportunity successful, while others are not? Why do some political actors not take advantage of windows of opportunity at all? In order to parse these questions more systematically, Tuohy focuses on both the scale and the pace of reforms. Scale is considered on a vertical axis running from small to large; pace is set on a horizontal axis running from gradual to simultaneous. This presents a model with four quadrants: large-scale reforms carried out quickly are labelled “big bang”; large-scale reforms that occur over a longer period of time are termed “blueprint”; piecemeal reforms that occur in a compressed period of time are “mosaic”; and piecemeal reforms that roll out over time are, of course, “incremental”. Using this theory of strategic domains, Tuohy sets out to understand why the United Kingdom (England after 1998), the United States, and the Netherlands embarked on the kinds of health care reform they did, and why the Canadian health care system resolutely failed to manifest significant reform at all since its inception in the 1960s. Even more interestingly, she attempts to explain how previous attempts at reform often changed the balance of influence between the key players (state, private finance, and the medical profession) such that new, and usually unanticipated, opportunities (or barriers) to consequent reform efforts were created.
As an attempt to impose clarity on a complex and confusing subject matter, Tuohy's schema is a comprehensive yet flexible evaluative framework that allows us to think more deeply about health policy reform in a comparative context. Yet it does face certain challenges. One issue is how cleanly cases fit into their assigned categories. Canadian reform in the 1960s, for example, is classified as a “big bang” model based upon the speed and scope of federal medical care legislation. Yet it can be argued that Canadian reform was both longer and more piecemeal than this classification assumes. Substantive health policy resides with the provinces; the Medical Care Act passed by Ottawa in 1966 was not in itself the substantive aspect of reform insofar as it merely enabled provinces to make policy changes of their own (each province doing this in a way that reflected provincial realities and opportunities). Moreover, the Medical Care Act must be considered in conjunction with the 1957 Hospital Insurance and Diagnostic Services Act, for a comprehensive account of major health reform. Given that this “reform” thus involved thirteen jurisdictions and was enacted gradually over a period from 1947 (when Saskatchewan introduced the first piece of legislation) to 1972 (when Newfoundland became the last province to take advantage of federal legislation), there seem to be clear elements of both blueprint and mosaic models here. Similarly, one could ask exactly when a “blueprint” design becomes an “incremental” one, or a “big bang” becomes a “mosaic”. “[T]he classification of cases into these types”, writes Tuohy, “is a matter of scholarly judgment” (28); and indeed it is—though this obscures the messiness that is often involved in situating cases in one category rather than another.
A second issue arises with the attribution of causation in the theory of strategic domains. The overarching hypothesis of the book is that “given the institutional and political conditions for making major change in health care policy, political actors adopt strategies driven by their assessment of their current and future position of influence as implied by these conditions” (524) and specifically their assessment of their control over the coalition of key political interests. In and of itself, this is not particularly remarkable, as it is doubtful that many political actors would engage in major reforms without making these strategic calculations. More interesting, however, are the more exacting hypotheses that Tuohy presents as functional extensions of her theory of strategic domains: first, that the greater degree and scope of large-scale policy reform provide more durability than piecemeal reforms, which can more easily be dismantled by hostile administrations at a later date; and second, that a quicker pace leads to greater conflict because veto points to be navigated are condensed in time. Tuohy's cases do seem to substantiate these claims. However, the perennial issue with small N studies (questions of selection bias aside) is that it is difficult to persuasively untangle causation from correlation. For example, Tuohy classifies the development of Medicare/Medicaid policies in the 1960s as “mosaic” strategies—a number of small-scale measures enacted contemporaneously. But why then have these policies been so durable? It is arguable that—irrespective of pace or scale—they have been so enduring simply because they provided public entitlements that, once given, were difficult to eliminate. On the basis of so few examples, it is difficult to determine whether pace and scale are important independent variables or merely confounders that correlate to phenomena but are not integral to their realization.
The word “logic” plays a major role in Tuohy's work. It refers to “a set of expectations about the rewards and sanctions attached to various actions” (51), and it grounds the narrative account of why actors choose one set of actions over others. It is this second intellectual task, constituting the majority of the book, which provides the depth and nuance that underpins Tuohy's theoretical framework. Her detailed and incisive accounts of the causal development of health reform in four jurisdictions (five, if one includes the case of Germany at the end) are carefully rendered and illuminating. It is this meticulous attention to detail (what is Medicare Part D? how did it come about? what were the implications of its establishment on future reforms?) that give this book such heft: one could disagree with all of Tuohy's theoretical claims and yet still gain an enormous amount of understanding from the empirical substance alone.
The third element of Tuohy's book is the most original and thought-provoking section. Here she posits that innovative health reform now lies in the capacity of a regime to “hybridize” public and private aspects of their health systems. This hybridization requires new institutional intersections across sectors that exercise authority under a public mandate. It is accomplished by agents she terms “institutional entrepreneurs”, who capitalize on policy entropy to push for institutional reform by combining control over key resources (public authority, private finance and professional expertise). Here lies the “agency” of policy change for contemporary states (and, in this way, Canada's strict proscription against the commingling of private and public resources in health care, as well as its tight bilateral monopoly between government and medical associations, explains the lack of substantive reform in that country). This is a captivating argument about policy change per se, but it is curiously devoid of any evaluation of whether these kinds of hybrid systems are a good thing or not: Are their outcomes superior? Are they more adept at addressing the perpetual problems of modern health care systems (access, quality, equity)? Explaining why change occurs is a worthy task, but it would also be useful to have a sense of whether this kind of change is to be emulated or avoided.
There are minor issues with the book. At times (especially toward the end), it felt as if there were simply too many moving parts: an elegant theory isn't too unwieldy. There are unit-of-analysis concerns (to what extent is focusing on England rather than the UK as a whole commensurate with focusing on Ontario rather than Canada?). A key figure (1.2) is mislabelled. Nonetheless, Remaking Policy is a formidable effort that attempts to push thinking about health reform well beyond tired paradigms and explanatory frameworks. It is thorough, inventive, and intellectually engaging. It will no doubt define comparative health policy analysis for years to come.
