Chapter 1: Overview

This introductory chapter sketches out the theoretical framework of the book, and introduces the national cases that form its empirical substance.

Preview of the argument:

Windows of opportunity for major change in policy frameworks are opened by conjunctions of broad political and institutional forces that give a governing party both the opportunity and the motive to forge a coalition for change and to overcome vetoes. But the scale and pace of change that is actually attempted depends on strategic judgments made by political actors within those windows. Four patterns of change are possible: big-bang (large scale, fast pace), blueprint (large scale, slow pace), mosaic (multiple small scale, fast pace) and incremental (small scale, slow pace). The choice among these strategies will turn first on whether or not the leaders of the winning coalition enjoy centralized control or must deal with other coalition members with independent power bases, and second on whether the various members of the coalition see their current positions of influence as precarious, stable or likely to improve.

Introduction of the cases:

The chapter also introduces the cases that will demonstrate how these dynamics have unfolded in four nations, emphasizing in particular the experience of the “millennial” period of three decades spanning the turn of the twentieth century. It sketches how the foundational policy logics of the health care state were transformed in that period in Britain, the Netherlands and the US, as each embarked in different ways of a set of “market-oriented” reforms, while the foundational logic of the Canadian health care states remained essentially unchanged. But it also situates those cases with others within a broad arc of welfare-state development, to lay out the ten cases that provide the empirical grist of the book. Britain’s establishment of the National Health Service in the 1940s and the “internal market” reforms of the NHS in the 1990s are examples of big-bang change, as is the adoption of Canadian medicare in the 1960s. The Dutch followed a “blueprint” strategy from 1988-2006 to transform their bifurcated social/private insurance system to a comprehensive system based on mandatory regulated coverage under formally private insurance. “Mosaic” strategies characterized the American adoption of Medicare and Medicaid in the 1960s, “Obamacare” in 2009-10 – while an attempt at big-bang change in the 1990s failed. Mosaic strategies also characterized the NHS reforms in England under the Coalition government in 2010-12. Finally, incremental strategies emerged as a deliberate strategic choice during windows of opportunity (not just as a default in “normal” times) in Canada’s federal system in 2002-04 and in the Labour government in England in 2002-07.

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