Carolyn Hughes Tuohy
Toronto, CA, University of Toronto Press, 2018, ISBN: 9781487502454; 688pp.; Price: £70.45
London School of Hygiene and Tropical Medicine
Date accessed: 28 September, 2020
These days, expenditure on health amounts on average to some 9 per cent of gross domestic product in the prosperous nations of the West. Whether through direct taxation, social security, social health insurance or private means, it’s a substantial amount. It’s no surprise then, that the politics of health care loom large amongst governments’ priorities, nor that those politics should be fiercely contested. President Trump’s efforts to unwind Obamacare, and the Brexit campaign’s notorious ‘bus’ lie about NHS funding exemplify the substantive issues at stake and the emotional power they exert. Hence the emergence of health policy analysis as a field of study, to which Carolyn Tuohy’s latest book makes a major new contribution.
This is a contemporary history of health policy-making in Britain, Canada, the Netherlands and the United States. The chronological flow is concertinaed, so that the immediate post-war developments up to the 1980s are briefly charted, and the lion’s share devoted to the ‘millennial’ period of the last 30 years or so. This follows Tuohy’s earlier work, Accidental Logics (1999), which examined the coming of organized health systems in Britain, the US and Canada to the 1990s. It showed how their formative moments determined the balance of power between state, market and medical profession, shaping the ‘logics’ of the policy arena that conditioned future change. Now she takes this story forward, against a backdrop of aging populations, technological advance and insatiable expectations, and a policy discourse that bubbled with controversy. What were the proper roles of public and private sectors? How should efficiency and effectiveness be best attained? And what place for the politics of equity?
Readers should note that this is first and foremost a work of political science, with the accent on science. In other words, Tuohy’s method is first to establish a conceptual model of the health policy-making process, then to use comparative cases to explore it empirically. Her aim is to derive generalisable observations applicable to other countries and to other fields of policy. This approach is not always beloved of historical scholars. In the preface to his comparative study of Anglo-German social policy under Bismarck and Lloyd George, Peter Hennock decried methodologies of ‘filling in the blank spaces in a pre-determined framework’. His point was that excessive concern with structural commonalties marginalized the importance of actors, ideas and the contingency of events, obscuring the extent to which each national trajectory was essentially sui generis. Reading Tuohy is therefore instructive, not simply for the history that she unfolds, but for gleaning what, in expert hands, a ‘framework’ approach can offer.
What does her conceptual model look like? Firstly, she argues that we can differentiate normal times of ‘policy-cycling’ from more momentous shifts – the ‘remaking policy’ of her title. Substantive reorganization occurs in such ‘remaking’ phases, affecting the balance of power and flow of resources between the different players in the health system. These are states, as arbiters and regulators, medical professionals, and the commercial or non-profit actors who run sickness insurance funds, or provide hospitals and services.
Such episodes of deeper change, she says, conform to four different patterns, depending on the strategy pursued by politicians. Some are of the ‘big-bang’ type, where the pace is fast and the scale large. The creation of the British NHS in 1945–8, the Thatcher/Major internal market reforms, and Canada’s introduction of Medicare, are examples. Others are ‘mosaics’, where the pace is rapid, but the form is of ‘multiple adjustments’ (p. 19) to the existing configuration, rather than upheaval. President Johnson’s establishment of Medicare and Medicaid for the United States in 1965, which left in place voluntary and private insurance is a case in point, as is Obamacare, and so too Andrew Lansley’s reforms under Britain’s Coalition government in 2010–12. Others again are ‘blueprints’. This is where the pace is staggered to phase in reform gradually, ensuring a reasonable consensus and sensible policy learning in the process. The Netherlands’ shift to a regulated private insurance model of comprehensive, universal cover, begun in the mid-1980s, is illustrative. Finally, there is the ‘incremental’ type of reform, where the pace is again gradual and the scale more modest. Canada’s adjustments to Medicare, and the Blair/Milburn creation of NHS trusts in the 2000s are examples.
Having delineated her fourfold typology, Tuohy then focuses on why these ‘remaking’ episodes happen. Here she draws particularly from John Kingdon, and his analysis of circumstances in which a ‘window’ for change opens. Partly this follows recognition of a problem with existing arrangements, forcing arguments about change onto the politicians’ agenda. Partly it reflects the emergence of viable proposals from the ‘policy soup’ of ideas for improvement. And partly, in liberal democracies, it hinges on a propitious electoral outcome that empowers politicians to enact legislation. Once these circumstances align, change can follow, though the strategy adopted will depend heavily on the political configuration. This is determined partly by features of the polity, and partly by contingent circumstances. Thus, Britain, with its occasionally large first-past-the-post majorities, and traditionally strong party whip, has had opportunities for ‘big-bang’ reforms, while the United States, with its division of powers and internal party cleavages, has tended to the ‘mosaic’ approach, even under Democratic Presidents.
The central sections of the book elaborate the four national cases. She explains the window for change that opened for Britain’s big-bang creation of the NHS in 1945–8 by the changed calculus presented by Clement Atlee’s election victory. Similarly, it was the numerical advantage of LBJ’s Democratic Party in the Congress of 1964 that finally allowed progressives to overrule the internal objections of Southern Democrats. The mosaic strategy of Medicare (adding health coverage for the over-65s to workers’ social security) and Medicaid (consolidating federal support for means-tested state health benefits for the poor) followed. Canada’s big-bang of 1966 was a move to a ‘single-payer’ model, also dubbed ‘Medicare’, where public expenditure was the main funding source for universal cover, but providers were diverse. Here the window depended on an alignment of co-operative working between the federal government and the provinces, and a sufficiently strong Liberal majority. Finally, there is the Netherlands, where a long tradition of private and mutualist sickness insurance existed. Early parliamentary efforts to convert this to a formalized Bismarck model had been repeatedly thwarted by political deadlock between the multiple small parties. This changed during the war, when German occupiers made insurance cover compulsory for workers in a regulated system. Tuohy observes (with some sleight of hand) that this is anomalous for her framework and ‘is not treated here as a case’ (p. 106).
Following the establishment of the ‘health care state’ in each country came phases of ‘policy cycling’. Unlike the major ruptures, these modest adjustments took place in response either to pressure from the interest groups involved, or to economic concerns. For example, in the NHS, the reforms of 1974, which created district and area health authorities fall into this category, and in the United States, the assertion of greater financial control over Medicare using payment formulae.
Next come the millennial reform episodes. Again, Tuohy focuses particularly on configurations of political power at moments when the window for action opened. Margaret Thatcher could carry through the ‘internal market’ project for the NHS (instituting the purchaser-provider split between the health authorities and the hospitals) because she was secure in power following a third election victory, and could override objections to risks of deep change. President Clinton, by contrast failed in his efforts of 1993–4 because he lacked the numbers to overcome a Senate filibuster. The Dutch blueprint approach was achievable over a long phase (1987–2006) because the ‘broad schematic’ (p. 330) was accepted within a multi-party polity acclimated to coalition government. Despite periodic rhetoric about breaking with the past, Dutch political culture retained a strong tendency to ‘poldering’ – the building of corporate consensus between key actors (the derivation refers to the collective solidarity necessary for reclaiming low-lying farmland, polders, through dyke-building).
Beyond the fundamental electoral determinants, Tuohy also gives some play to individual agency. Thus, Nancy Pelosi’s arm-twisting guile and tactical sense were vital to the Obama reforms, particularly in 2010 when failure threatened after the loss of a crucial Senate seat. Similarly, the personal animus between Tony Blair and Gordon Brown was a limiting factor in New Labour ambitions, pushing them towards incrementalism.
Following the main survey, a lengthy additional chapter presents the role of another kind of agent, the ‘institutional entrepreneurs’, as a final explanatory component. The allusion to economic enterprise is deliberate. Within the health system ‘entrepreneurship’ may be for private profit, as in American commercial medical insurance, or it may be focused on gains in managerial freedoms, as in the English GP fundholding model of the 1990s. What these have in common is that they are unanticipated responses to the new policy direction set, with individuals optimising their position, and thereby reshaping the trajectory of the future. The idea is akin to that of ‘increasing returns’ within path dependency theory, whereby the investment by users in a particular technology or policy creates a strong lobby for its retention, even if evidence mounts that it is sub-optimal.
What insights does all this bring? The idea of a transferable model is that it should yield lessons on which future policy-makers can draw, and which can illuminate processes of change for the rest of us. Tuohy convincingly shows us that the core considerations are the scale and pace of a proposed reform, within the institutional context conferred by history. Effective politicians are those who calibrate carefully the ambition of policy objectives against the timetable required to embed them, in light of the current and future influence their party wields. Success comes to those who choose the right strategy according to this calculus, and make a realistic appraisal of the legislative obstacle course and passage to implementation.
These are powerful and important lessons that anyone venturing into the terrain ought to heed. They also speak to concerned citizens, wondering which mode of constitutional government might best serve the public interest. Tuohy studiously avoids value judgments about her cases, but after reading her, who would not wish to see their own country adopt the mode of Dutch health policy poldering, in which long-term planning, learning from evidence and cross-party consensus are engrained?
If these are the policy insights, how well does the book serve as a larger study of the health care state at the turn of the 21st century? Historians averse to political science will likely raise objections to the ‘predetermined framework’ approach. For one thing, the distinction between Tuohy’s ‘remaking policy’ ruptures and normal ‘policy-cycling’ is not always clear-cut. From the perspective of the British NHS for example, the 1975 Resources Allocation Working Party began a rather important incremental shift in the way funding was dispensed from the centre to the regions, though this is not deemed a ‘remaking’ episode. Meanwhile the ‘mosaic’ of the Lansley reforms could equally be seen as the final (incremental) fruition of the process first implemented in 1991, of refashioning NHS management as a commissioning relationship between quasi-autonomous bodies. (And best not to ask how to categorise the post-Lansley administrative reconfigurations, like the Devo-health interlude, aligning NHS and local government, or the Sustainability and Transformation Plan ‘footprints’, hastily assembled when it was realized that the destruction of local health authorities had left no organisation capable of ‘rationalising’ hospital capacity under austerity.)
Another problem is that while Tuohy’s ‘remaking’ episodes are distinctive from the point of view of the political class, they may not have seemed so to the public. In the British NHS, the purported big bang of 1989–90 has hardly lingered in popular memory like that of 1948. This is because it did not alter the availability of services free at the point of use, nor impose any change of access between patient and GP. For the ordinary citizen, the more crucial policy decision of the Thatcher years was surely the imposition of tight ceilings on expenditure growth, which by 1987 had fostered broad dissatisfaction with the service. Similarly, the Blair-Brown period mattered most for the decision in 2001 to raise health spending as proportion of GDP up to European levels, finally driving down waiting times and boosting satisfaction. From this perspective, the Coalition government’s most significant move was its drastic curb on NHS expenditure growth from 2010, which, coupled with harsh cuts to local authority social care, intensified pressure on providers. For patients at the interface with the service, here was where ‘policy’ translated into lived experience.
In the United States, a similar point could be made from the perspective of Southern African Americans in the Medicare/Medicaid era. Here, the desegregation of the hospitals was an equally fundamental shift in power and resources. Despite its rapidity, this was hardly a ‘policy’ rupture of the Tuohy type, for Jim Crow apartheid practices were not overturned by governments. Instead it was legal judgments against racial discrimination by hospital authorities, brought by black activist plaintiffs, which bounced the state into action.
These examples serve to remind that behind the politics of health care lie larger social conflicts, for which parties acts as proxies. Welfare state histories up to the 1990s were premised on this – what Gøsta Esping-Anderson called the ‘power resource’ theory of social policy. Crudely it assumes that where the interests of the working class were represented by social democratic parties, then welfare states were more expansive and generous. Where the middle class had the advantage, through the dominance of liberal or Christian democrat parties, then retrenchment was more likely.
Tuohy nods to this in her description of the coming of health systems in the mid-20th century driven by ‘class conflict, ideological debate ... and contests among peak associations’ (p. 21). Yet she does not follow it through into the later period, where partisan health policies float largely free of underlying social cleavages. It is obviously true that loyalties of class and party have lately been in flux, given the existence of blue-collar Trump supporters, proletarian Dutch populists and working-class British Tories. Yet it is also the case that, for example, the US Democratic party enjoys disproportionate support from poor and African American voters, and that it was Democratic Presidents, from Johnson, to Clinton, to Obama, who pushed for extending health coverage. Or that rates of real increase in British NHS budgets have been more restrained under Conservative administrations of the 1950s, 1980s and 2010s, whose bedrock vote was the middle class. Race and class may be obscured, yet they are still present.
There is one further way of thinking about health systems, which the method of single-country comparisons closes off. This is to see the health care state as a transnational phenomenon. Because how important, really, are the differences between the favoured Western nations which the book recounts? Yes, the policy outcomes had their trade-offs, between equity, cost-control and consumer satisfaction, and these had real ramifications for citizens at the receiving end. But they would surely seem small distinctions to a rural dweller of a poor country in sub-Saharan Africa, for whom access to the full benefits of biomedicine remains a distant dream. For all their dissimilarities, the cases here have much in common.
Dissolving the conceptual boundaries of the nation state raises one direct set of questions for Tuohy’s analysis. This is to consider more fully the extent to which the circulation of policy ideas was a transnational experience with established vectors of exchange. In today’s globalised world, awareness of developments elsewhere has become (as Rudolf Klein once put it) ‘... rather like breathing: only the brain-dead are likely to avoid the experience’. International organizations collect and promulgate information. Politicians and bureaucrats scan beyond their frontiers for ideas. And an epistemic community of academics and consultants purveys its wares, interpreting the global economic imperatives bearing on all governments, and proffering policy nostrums. Some elements of this creep into the story, for example when cost-containment rose up the West’s agenda in the 1980s. Common responses included the influence of the Diagnostic Related Groups technique for pricing medical activity, or the enthusiasm for the ideas of Alain Enthoven, the US economist who hatched the notion of the internal market. Yet Tuohy’s method necessarily underplays the extent to which the welfare state is, and has always been, shaped by cross-border diffusion. In Britain, as far back as 1911, national health insurance legislation was substantially modeled on the Bismarckian template. Fittingly, the memoir of the civil servant dispatched to Germany to pilfer ideas recalls how he conveyed his report to Lloyd George on the pier at Nice, during the Chancellor’s Riviera holiday. Our first health big bang was distinctly European.
Thinking outside national silos also raises questions about a future world in which rights to health can transcend borders. Possession of a European Health Insurance Card already confers on travelers to any county in the European Economic Area the right to necessary health care at free or reduced cost. Leaving aside the Brexit-shaped caveat, this surely augurs deeper regional integration, in which mobile populations of workers or retirees gain eligibility to increasingly homogenized health systems.
If so, then the attention of analysts may move from the variations between Western nations, to the equally challenging policy question of how the health security enjoyed in the rich world may be extended globally. As things currently stand, the World Bank and World Health Organization are advocating for a costed bundle of essential health services to become available to all. 2019 is set to be the year the United Nations campaigns for universal health coverage as a global goal. In addition to the commitment of national governments in poorer countries, this will also mean at least a doubling of aid budgets for health from the prosperous West. Were it to happen, the scholars who come in Tuohy’s wake will find themselves with a large, and very different canvas, on which to explore patterns of scale, pace and strategy for reform.