Part III moves to the reform of the millennial era from the mid-1980s to the present. Chapters 5-7 deal with Britain and the US, which despite their stark institutional differences exhibit some remarkable similarities of strategies in contemporaneous episodes in the early 1990s and again roughly two decades later. Chapter 5 takes us from the early 1990s to the end of first decade of the twenty-first century. The beginning of this period was the era of big-bang strategies – leading to success in enacting a new policy framework in the UK but to failure to do so in the US. The Thatcher Conservatives seized a moment created by a third successive majority to introduce a sweeping reform aimed at establishing ownership of the health policy agenda before the next election. In the US, the Clinton administration misread the political circumstances to attempt a big-bang change when at most a mosaic might have succeeded. After that, policy-makers in both nations cycled through the prevailing policy repertoire in a series of incremental changes from the mid-1990s to the late 2000s.
The pattern of cycling under Labour in England in the 2000s presents a significant puzzle. Windows of opportunity opened not only in 1989 and 2010, but also in 2002. Why, in the context of an historic second consecutive landslide victory, did the Blair government not seize the moment to re-draft the policy framework for the NHS as part of its New Labour agenda for public service reform? I argue that the incrementalism of the New Labour government needs to be understood not as a default in the absence of the opening of a window of opportunity, but as a deliberate response to the opportunity it was given – a strategic decision driven by the rivalry of two towering figures, Tony Blair and Gordon Brown.
Chapters 6 and Chapter 7 then deal with the twin American and English mosaics in the middle of the first two decades of the twenty-first century: the Obama reforms (the Affordable Care Act of 2010) in the US and the Coalition reforms (the Health and Social Care Act of 2012) in England. Each occurred at moments when the would-be reformers found themselves in institutional and electoral circumstances that were both extraordinary and precarious. In each case they read those circumstances as both enabling and requiring them to rapidly build coalitions through multiple compromises that yielded myriad small-scale simultaneous to the prevailing framework while evoking ferocious partisan opposition and public hostility. In the American case this opposition culminated in yet another episode of attempted change, again on a mosaic strategy, when the Republicans gained control of both houses of Congress and the White House in 2017. Although this latter episode is not treated at as great length as the others in this book, it nonetheless adds another case to the mix.
Chapter 8 analyses our single example of a blueprint strategy: the Dutch reforms legislatively begun in 1989 and concluded in 2006. The uniqueness of this example is despite the attractiveness of such a strategy from a policy-maker’s perspective. In theory, it should allow for taking account of the multiple trade-offs and inter-connections inherent in health policy by building and winning assent for a comprehensive design up-front, and then putting the pieces of that design in place over time as the various technical and organizational capacity is developed – a timeframe extending beyond the tenure of the initiating government. That such strategies are so rare is testimony to the highly usual nature of the political circumstances in which they are likely to be generated: the members of the winning coalition for reform must have a reasonable expectation that they will continue to be in a position to enforce the balance of the overall compromise as each subsequent stage is enacted, giving each an incentive to participate in designing a commonly-agreed framework.
The Dutch case also demonstrates the key feature of blueprint strategies – not that the steps originally contemplated are followed to the letter, but they establish a “shadow of the future” that forms expectations and leads various actors to adjust their behavior in ways that both facilitate and shape the subsequent steps.
Chapter 9 presents the final case of Canada in the early 2000s. Like the case of British Labour in the same period, the Canadian case demonstrates that incrementalism is not only the default, or “normal” mode for policy change on the periods between rare episodes of major change, but is also a strategic option that may be deliberately chosen even when normal constraints are relaxed within windows of opportunity for major change. Health care had moved to the centre of the intergovernmental agenda after decades of being held hostage to constitutional wrangling, and the fiscal climate favoured “re-investment” after a period of restraint. A federal Liberal government in the course of a leadership transition and facing declining electoral fortunes was determined to recapture public confidence on one of its signature legacy policy domains, health care. The provinces, for their part, were determined to capitalize on the relatively buoyant fiscal and economic conditions to recapture the federal funding that had been eroded over the previous two decades. But because shifting political circumstances destabilized the federal-provincial balance, various actors judged that they could use that moment to make changes that would enhance their ability to enact further change in the future without the need to share political credit. The result was a set of “accords” embodying the minimum set of changes to which they could all agree.