Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada
Health care reform has become one of the most prevalent topics in recent policy discourse within and across nations. In the 1990s, common features of the health care arena elevated the importance of bargaining relationships among large, sophisticated entities as the dominant mode of decision-making, fundamentally challenging the traditional dominance of the medical profession, which had been grounded in individualized "agency" relationships between providers and patients. These developments have played out in varying ways around the globe. Carolyn Hughes Tuohy looks at the experiences of the United States, Britain, and Canada, offering an international comparative study of public policy systems, as well as a recent history of the evolution of each national health care system. What drives change in health care systems? Why do certain changes occur in some nations and not in others? Tuohy argues that the answer lies in understanding the "accidents" of history that have shaped national systems at critical moments and in the distinctive "logics" of these systems. Her study carefully delineates both the common logic of the health care arena, deriving from micro-economic characteristics and technological change, and the particular logics of national systems, put in place by specific episodes of policy change. She goes on to explore how in the wake of these episodes, the mixed market in the United States, hierarchical corporatism in Britain, and the single-payer system in Canada determined the subsequent direction and pace of change in all three countries. Finally, Tuohy provides suggestions to guide the strategic judgments that decision-makers must make within the health care system of each country. Accidental Logics uniquely departs from the descriptive literature currently available by presenting an extensive review of the evidence regarding the evolution of the health care arenas in the United States, Britain, and Canada, integrated within an explanatory framework. It is essential up-to-date reading for political scientists working in comparative politics and public policy, health policy analysts, government agency officials, and students in political science, health policy, and administration programs.
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PART I EPISODES OF POLICY CHANGE
PART II THE DISTINCTIVE LOGICS OF NATIONAL SYSTEMS
accommodation actors adopted agency relationships agenda American audit authority Britain British Columbia broad Canada Health Act Canadian medicare chapter clinical audit Clinton coalition collegial networks competition context contracts corporatism corporatist costs coverage decision-making systems decisions Democratic DHAs employer mandate established expenditures federal government federal—provincial fee-for-service fiscal for-profit fundholding funding global budget governmental groups health care arena health care delivery health care reform health policy hierarchical HMOs hospital sector income increased individual institutional mix internal market reforms Klein Labour legislation logic major policy change managed managed care Medicaid Medical Association medical audit medical profession ment national health insurance negotiations not-for-profit OECD Ontario organizations patients payers physicians political practice practitioners private finance private insurance private sector profession—state professional proposals providers provincial governments purchasing Quebec regional role Saskatchewan social strategy structural balance tion United windows of opportunity