Institutional Entrepreneurs and the Politics of Redesigning the Welfare State: The Case of Health Care

52 Pages Posted: 15 Jul 2012 Last revised: 28 Aug 2012

See all articles by Carolyn Hughes Tuohy

Carolyn Hughes Tuohy

University of Toronto - Department of Political Science

Date Written: 2012


Institutional entrepreneurs reconfigure control of different bases of power, across the public and private sectors. They are thus to be distinguished from policy innovators within the public sector and from commercial entrepreneurs within the private sector. Market-oriented policies in Britain, the Netherlands and the US, by attempting to introduce and/or harness market forces in combination with public funding and regulation, disrupted established relationships and established new footholds for multiple actors to undertake entrepreneurial activity spanning the public and private sectors. The very fact of large-scale policy change, moreover, created political and technical uncertainty around the future course of reforms. Hence the classical conditions for entrepreneurialism – heterogeneity and uncertainty – were put in place. Differences in the scale and pace of reform made for differences in the degree of heterogeneity and in the timing and duration of periods of uncertainty.

Institutional entrepreneurs emerged from different bases, behaved in different ways and had different impacts in the three countries. Entrepreneurialism emerged principally within the ranks of providers in England, insurers in the Netherlands and state actors in the US. The bases from which these entrepreneurs emerged were determined initially by the nature of the policies adopted during moments of major policy change. In that sense, policy shaped entrepreneurial behaviour. But once institutional entrepreneurs had seized the opportunities created by the new policy frameworks, their behaviour shaped the ensuing course of policy development, and in various ways laid the groundwork for the next major episode of change. That behaviour was constrained by the existing political economy of health care. But those institutional entrepreneurs who succeeded (and not all did) expanded their power bases, even as the arrangements they created channeled the exercise of that power in new ways.

Suggested Citation

Tuohy, Carolyn Hughes, Institutional Entrepreneurs and the Politics of Redesigning the Welfare State: The Case of Health Care (2012). APSA 2012 Annual Meeting Paper, Available at SSRN:

Carolyn Hughes Tuohy (Contact Author)

University of Toronto - Department of Political Science ( email )

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