Ten years ago, there were relatively few political science texts on health care—the only truly comparative treatise by Odin Anderson was published in 1972, a book dealing with postwar medicine in Britain, Sweden, and the United States. (And Anderson was a sociologist.) It is not that health care was ignored, but the ferment was most evident in the growth of health economics texts.

Yet, over the last decade, there has been a literal explosion in comparative studies by political scientists and others. Academic conferences on comparative health studies have attracted many scholars. A spate of comparative reports by international organizations such as the OECD and WHO has provoked commentary and controversy, as well as supplying a wealth of comparative data. Now we see a third stage, one of book-length treatment, four of which this review examines. (Two other works of comparative politics came to my attention too late for review here. One is the admirable 1998 portrait of Japanese medical care—contrasted with that of the United States—by John Campbell and Naoki Ikegami, The Art of Balance in Health Policy, 1998. The other is Colleen Flood's wide-ranging “legal, economic, and political analysis” of International Health Care Reform, 2000.)

One can evaluate this literature by, at a minimum, two standards. One is the degree to which the work advances our understanding of how and why various nations have developed their health-care systems. The second is the extent to which the analysis permits readers to draw plausible policy lessons—predictive and prescriptive—for the national systems studied? The issue for this essay is, How well do the four scholarly works of comparative politics under review satisfy these standards?

Tuohy's Accidental Logics stands out as a sophisticated, thorough, and insightful synthesis of comparative politics and policy in Canada, the United States, and Britain. As she makes clear in her title, the book concentrates on explaining patterns of policy continuity and change, buttressed by a thorough understanding of both the institutional details of modern health care and the demands of comparative political analysis.

Tuohy's central thesis is that a “common logic” dominates health-care policy cross-nationally. But, she argues convincingly, the working-out of that logic in any given country reflects the “accidents” of history, the combination of which gives rise to each country's particular national system. Tuohy examines the national relationships between the market and the state in health care along two common dimensions: the balance of influence among types of actors (state, private finance, and health-care professionals) and the mix of instruments of social control (hierarchy, market, and collegiality). This framework not only descriptively illuminates the medical care we see, but also enhances the reader's understanding of seeming puzzles in the tumultuous area of health care policy. Tuohy's discussion of the United States over the past two decades illustrates her contribution. She understands recent American health-care developments as a result of the intersection of “the logic of entrepreneurialism inherent in market-based systems” and the increasing “influence of private financial actors at the expense of the medical profession” (pp. 158–9). Her general medical-care discussion reflects as well a profound scholarly understanding of the complexity of professional regulation. And her analysis of professional autonomy highlights the centrality of physicians, a group that has influenced and continues to influence health-care policy everywhere in the world of industrial democracies.

Accidental Logics begins by noting the features of medical care that make it the object of intense policy concern, analyzing the pressures for change internal and external to contemporary national health arrangements. The speed of change in the three countries she studies intensively differs according to the particular “institutional mix” (defined as the degree of government hierarchical control, market forces, and professional collegiality) and the “structural balance” among state, medical professionals, and private financial interests. With this approach, Tuohy then illuminates the variation in the impact of reform ideas on policy practice in the three Anglophone nations she knows so well. Substantively, Tuohy gives us national portraits that conflict with much conventional wisdom: comparative stability in the basic policy framework of Canada since the 1960s, tumultuous change in the United States in the 1990s, and a more limited degree of change in the world of British medicine from Thatcher to Blair.

Richard Freeman's contribution is of a different order. His book's scope is very ambitious. It is about,” as he states on the first page, “health, politics, and Europe.” The central question for the non-health-care specialist is whether the focus on publicly provided health care—which is what Freeman really has in mind, as opposed to the broader topic of health—illuminates European politics in especially striking ways. For health politics specialists, the issue is how the book's theoretical or empirical content advances the understanding of the subject.

Freeman's book is a readable, useful guide for the nonspecialist to the shape of European health-care systems, their origins, major institutional features, and contemporary disputes. (By contemporary, I mean over the last two decades of the 20th century.) Indeed, the focus of the empirical chapters is the disputes about “re-forming” health care that have raged since the stagflation of the 1970s in France and Germany, Italy, Sweden, and Great Britain. Freeman's title might well have been the “politics of health reform in five European States,” emphasizing the pressures for change from those who use public health care, those who provide it, and those who pay for it.

The treatment of this subject is sensible, solidly documented, and very valuable for those trying to make sense of the very complicated, ever-growing arena of health-care funding, delivery, and regulation. The sequence of chapters begins with an introduction to the questions and the approach Freeman will take. It then moves to a very brief, but helpful sketch of European health-care politics in the century from 1880 to 1980 and takes up in comparative chapters the five national health-care programs. Freeman divides the substantive, descriptive chapters in two, distinguishing “national health services” (Italy, Sweden, and the United Kingdom) from what he conventionally labels as “social insurance systems” (France and Germany). Readers could use this dichotomy to analyze the health arrangements of other countries in western Europe, putting Holland and Belgium into the latter camp and Norway, perhaps, in the former one. Doing so would, however, raise the question of whether this particular classification is all that helpful. Does it really illuminate the political struggles over health care across Europe? Is thinking about policy arenas in terms of legal ownership/financial categories such as social insurance and national health service all that helpful in understanding what health policy matters are at issue and what patterns of resolution emerged in the Europe of the late 20th century?

The answer for this reviewer is simple. The formal designation of social insurance or national health service is but one of the potential factors shaping health-care politics and deserves no particular privileged status. Freeman concedes that the distinction is “not real” but “makes a wealth of information more manageable” (p. x). In fact, he regards the study of particular disputes in health care as warranting different analytical approaches, “necessarily eclectic,” as he puts the point (p. viii). So what the reader has here is an accurate sketch of European political/medical history, a well-informed summary of salient disputes in five of Europe's nations, and some interesting, but not fully developed approaches to understanding why health-care policies and programs have worked out as they have.

For scholars (and students) of comparative politics, it will be a valuable substitute for the outdated work of Odin Anderson, a useful companion to the descriptive, statistical portraits of the OECD, and a helpful companion to the many articles on particular disputes or national programs.

What the specialist reader will find disappointing, however, follows precisely from the virtues of the book for the general reader. This is an excellent synthesis of available understandings. But there is little that advances that understanding, or reveals why and how comparative analysis can make a substantial difference in how we either explain comparative policy development or inform policy disputes about health care with an understanding of the crucial political constraints that research has revealed. Freeman does make a good case for adapting theoretical approaches to the different disputes within medical care but does not provide an especially illuminating way to conceptualize that. He suggests rightly that, for both explanation and evaluation, the comparative method is as close to experimentation as social science is likely to get. But, there again, the justification of the comparative approach does not produce in practice an explanation of change and continuity that goes beyond conventional national accounts. For that topic, Accidental Logics is superior. Freeman's contribution, however, is no less worthy for being synthetic rather than a theory-building exercise.

Michael Moran's Governing the Health Care State takes as its central question the following: How can one explain the embrace by the Thatcher government of American-inspired market reforms of the 1980s and early 1990s? The puzzle arises because the apparent motivation of those reforms—the control of health-care costs—was something that the unified government of the NHS was already capable of doing. The answer to that puzzle, Moran argues, can be revealed only by cross-national analysis. And his investigation is part of a broader concern about why “in the early 1990s the health care systems of most of the advanced capitalist nations were reformed” (p. x).

Moran's book, like Freeman's, offers a standard, competent description of the main health-care features of the United States, the United Kingdom, and Germany. But the patterns emphasized are not as illuminating as promised. The interplay of health-care institutions and the state constitute what this book regards as its central “insight,” leading Moran to emphasize the analytical importance of what he terms the “health care state” (p. 10). This conception—health care as a subunit, so to speak, of the welfare state—defines the “closed loop feedback mechanism” of interaction between health-care interests (those of patients, providers, payers, drug firms, device manufacturers, etc.) and the political order. It is surely true that industrial democracies expend (publicly and privately) vast sums on health care. These in turn create a complex set of economic and political pressures. But to note that is not, in my view, to advance the reader's understanding appreciably.

The Moran analysis breaks out three elements of the “health care state”—consumption politics (access and cost), professional politics (expertise, ideology, and pressure groups), and production politics (health care as an industry commanding a substantial share of the GNP). The work is most helpful in dealing with consumption politics (chapter 3) and summarizes well developments in that sphere in the three countries. The other parts of the triumvirate are less well treated. For example, Moran unconvincingly regards the politics of professional regulation as simply what economists call “rent-seeking” by the medical professions, a “chance to gain competitive advantages in markets by securing preferential policy outcomes” (p. 14). There is no doubt that many regard professional self-regulation as simply window dressing for economic advantage. But one hopes for a more sophisticated discussion of such topics when issues of the quality of care are real and, in the case of the United Kingdom, a central feature of current criticisms of the NHS.

Moran returns in the end to his initial puzzle of why the United Kingdom turned in the latter 1980s to reform models inspired, he claims, by U.S. intellectual entrepreneurs. His unremarkable conclusion is that “the form and direction of health care policy are responding to some forces deeper than pressure for cost containment” (p. 174). But Moran is unable to explain precisely why precisely the particular class of innovations appealed, although along the way the reader receives an overview of changes taking place in all three political and health-care systems. Descriptively helpful, this book promises more than it delivers in making sense of continuity and change in the health-care arrangements of these three democracies.

Charles Andrain's book on inequality and public health is the most ambitious of the works under review and the most disappointing. Andrain approaches health-care policies deductively. He treats the topic as derivative of three models of the modern welfare state, using Gosta Esping-Anderson's typology as his organizing analytic framework in Part I of the book. He attempts to describe and explain developments in eight countries, placing each in one of the three welfare-state models—entrepreneurial, organic corporatist, and social democratic. Canada and the United States are treated as instances of the first category; Germany, Holland, Japan, and France exemplify the second; and Sweden and Britain are examples of the social democratic mode. It is unclear whether Andrain uses these categories to characterize the respective governments per se as the predicate for understanding its health policies or whether, as he sometimes suggests, these models reflect his understanding of each countries health-care features (pp. 14–5). To the extent that it is the latter, one must wonder about the applicability of these models.

Consider the result for Canada. Its universal coverage, global provincial budgets, and bans on extra billing and supplementary health insurance place Canada, according to Andrain's scheme, in the same “entrepreneurial” category as the United States, with its hundreds of health insurance firms, millions of uninsured and underinsured, and no overall budget setting by government (p. 19). On the one hand, there is no doubt that Canada' economic system and national culture resembles the United States' more than it does Sweden's (Andrain's exemplar of social democracy). But that fact does not substantiate the claim that Canada's medical-care arrangements rest on core entrepreneurial values—as opposed to those of corporatism or social democracy. Indeed, Canada's hospital and physician insurance arrangements are among the world's most egalitarian, and I can think of no specialist literature that supports Andrain's conclusion here.

Andrain's mistaken treatment of Canada is worth emphazing because it illustrates a key weakness of his approach to the comparative study of public policy, health, and social inequality. That weakness is empirical, the absence of a firm command of the literature on health-care systems. (His footnotes are extensive, but they come clustered at the end of paragraphs that do not link particular pieces of evidence with a specific argument. In that sense they reveal industry more than accuracy.) Canadians, we are told, “live “under a more decentralized system than the Americans” (p. 36). This characterization reflects the powerful role played by provincial governments in administering Canadian Medicare. The implication is that substantial variation exists in Canada because of that provincial administration of a program whose core features are actually enshrined in federal legislation. The fact is that Canadians—across the provinces—have in their hospital and medical insurance a substantially common policy. But this does not imply—unfortunately it does for Andrain—that the United States is more centralized. By most measures America's nonuniversal “system” has a smaller role for government of any type, whether federal or state, and reflects substantial decentralization of health-care policy and practice. The constraints of Andrain's deductive approach not only produces mischaracterization in this particular instance, but also undermines the credibility of his entire enterprise. Andrain begins with the presumption that “social inequality influences public health policies and their outcomes on people's health” (p. ix). That presumption, rather than a careful analysis of health-care policy, dominates the subsequent interpretations.

Even more fundamentally, this book rests on a conflation of public health and health-care policy. For Andrain, “public health policies” encompass all government decision making about health-care funding and allocation. At times, the term expands to include environmental, worker-safety, and labor policies. So what is presented is the work of a political scientist most interested in social inequality and governance, where health policy broadly understood is a vehicle for describing what is worthy and unworthy public policy. Social democratic governments, Andrain's logic suggests, “should promote the equality of workers,” while entrepreneurial systems are presumed to reflect “fragmented power structure[s]” where “low income people must rely on public health programs for their health care services, [programs] based on means-tests [that] usually supply niggardly benefits” (p. 15). This logic, however, makes incomprehensible either Canadian Medicare or American Medicare.

Understanding health-care systems and how they fit into their political setting is demanding. It requires analysis that is both theoretically illuminating and substantively accurate. Judged by these exacting standards, the Tuohy book is an extraordinary work, concentrating more on explaining policy developments than designing a framework for evaluating reform options. The other three books fall short of her exacting comparative standard, but in quite different ways. Freeman's contribution is that of synthesis, not theoretical advance. In the case of Moran's work, the analytic contribution promises more than it delivers, though the book's comparative portraiture will be useful to many teachers and students. In contrast, the Andrain book is, to this reviewer, an unhelpful contribution to the comparative politics of health care.

The comparative politics field, however, gains from this expansion of scholarship into health-care politics. Not only is health care central to the fiscal status of most governments—consuming an average of approximately 9% of the GNP among OECD nations—but the arrangements of care prompt intense political conflict. The varieties of those conflicts are substantial—from the moral disputes over cloning, abortion, and assisted suicide to the intense labor struggles over hospital closures and union organization, from the ideological struggles over rationing to the distributive struggles over research funds. Charting and explaining these differences more fully remain on the agenda for future works on health care and comparative politics.