Paths of Progress in Healthcare Reform: The Scale and Pace of Change in Four Advanced Nations
52 Pages Posted: 19 Jul 2010 Last revised: 12 Jul 2011
Date Written: August 28, 2010
In the past two decades, three cases of major change in health policy frameworks in advanced nations stand out in comparative perspective: the British “internal market” reforms of the 1990s, the Dutch introduction of universal managed competition among insurers in 2006, and the enactment of a universal mandate for health insurance in the US. Each of these cases represents a substantial shift from the foundational model of the nation’s health care state, either on a large scale, at a rapid pace, or both. The intersection of these two dimensions of scale and pace yields four possible strategies for policy change: big-bang (exhibited by the UK), blueprint (the Netherlands), mosaic (US) and, by default, incremental (exhibited in the current study by the case of Canada). These respective strategies can be understood as the result of judgments made by key actors under particular circumstances in the broader political and institutional context in each nation. Rare conjunctures of forces exogenous to the health care arena create opportunities for major change, but favour different strategies in different contexts. In the absence of such conjunctures, tensions inherent to health care delivery drive a pattern of cycling through established policy repertoires.
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