Piali Roy

Carolyn Tuohy is Professor Emeritus and Founding Fellow in Public Policy at the Munk School of Global Affairs and Public Policy whose focus is on comparative health care policy. Her latest book, Remaking Policy: Scale, Pace and Political Strategy in Health Care Reform (U of T Press, 2018), takes a theoretical lens to policy change in Canada, the United States, Britain, and the Netherlands. Here, she discusses a few of Remaking Policy’s key points ahead of the book launch on October 16. Register for the launch event here.

How did you arrive at the conclusion that there needed to be a different way of looking at policy change?

The process really started for me in the early 2000s, not long after the publication of my previous book, Accidental Logics: the Dynamics of Change in the Health Care Arena in the United States, Britain and Canada. In that book I, like others who study policy change, worked with a dichotomous model, contrasting periodic bursts of “big-bang” change with the incrementalism that was the norm between those episodes. But as I looked at another case of health care reform underway at that time, in the Netherlands, I realized that this dichotomous model couldn’t explain the transformation of the Dutch system over a period spanning the lives of several governments of different partisan stripes, toward a model the rough outlines of which had been agreed at the beginning. I realized then that we need to distinguish between the scale and the pace of change, and that choices of scale and pace are matters of political strategy.

Why are the issues of the “scale of change” and “windows of opportunity” important?

The scale of change that I am interested in has to do with the fundamental logic of decision-making about the allocation of resources. Who decides? What sanctions are available do those decision-maker to enforce their decisions? And what overall principles of legitimacy – about the grounds of entitlement and obligation, and about the function of the state – govern the making and enforcing of decisions? These are basic features of any policy arena, and changes in those features are more consequential than, say, increases or decreases in public spending. As long as those increased or decreased funds flow through the same channels of decision-making, we cannot speak of transformative change.

I would also point out that we need to be equally attentive to defining the “pace” of change, I am principally interested in the pace of enactment when policy changes are hard-wired into legislation. In that regard what matters is whether policy change is enacted within the life of a particular government, or whether the strategy extends beyond the next election.

The concept of a “window of opportunity” as a way of understanding major policy change is familiar in political science, at least since the work of John Kingdon in the 1980s. But it has always suffered from the risk of tautological reasoning – inferring the opening of a window of opportunity from the observation that major change occurred.  My contribution is to distinguish between the factors that open windows of opportunity and the strategic decisions that are made once the window is open. And that allows us to see that a window can open (that is, decision-makers can have the opportunity and motive to undertake major change) yet they can still choose strategically to pursue an incremental course – as indeed happened in Canada and Britain in the early 2000s.

You go beyond the “big bang” approach (large-scale and fast-paced), and the “incremental” (small scale and rapid), to include what you call the “blueprint” (large-scale and slow-paced), and the “mosaic” (small-scale and rapid), styles of policy change. What determines which strategy is used and when?

The choice of strategy depends on how politicians read their current positions of power, and what their expectations are about the position they will have in the future. A big-bang is likely where leaders can command support on the basis of institutional rules or common interest, but where they risk losing that position at the next election. A blueprint requires that leaders be able to build a broad-based coalition through negotiation, all of whose members believe that they will continue to be in positions of influence beyond the next election (a very rare set of circumstances). A mosaic results when leaders must negotiate reform with a variety of other actors with independent power bases, and all or most members of the coalition risk losing influence after the next election. Finally, incremental change can occur when leaders must negotiate change with independent actors but expect that their position could improve after the next election.

What are some of the challenges facing policymakers and politicians in making change?

The principal challenge is overcoming resistance from those whose agreement is essential in order to enact policy change. Political scientists refer to this as overcoming vetoes in order to build a winning coalition. This is somewhat easier in political systems with party discipline (such as Britain and Canada), which allow leaders with a majority in the legislature to insist on the support of their elected members, than it is in systems in which legislators have independent power bases (such as the US), and/or in which no party has a majority (such as the Netherlands). But in almost all cases leaders will have to negotiate to some degree, ether within or across parties or both, with the further challenge of maintaining the coherence of the overall policy package.  (The Affordable Care Act – “Obamacare” – demonstrated that challenge in spades.) And even after enactment, interests who were excluded during the enactment phase will have to be confronted again in implementing the policy change.

What is the role of the “institutional entrepreneur” in the case of reform?

The focus of most of my book is on the “high politics” at the centre of government, well beyond the health care arena. But when we turn to look at how these policies actually play out in the health care arena itself, the role of institutional entrepreneurs stands out. The concept is more specific than that of a “change agent.” I build on a growing literature on institutional entrepreneurs to tie it more closely to the original economic meaning of the term entrepreneur as one who combines resources in new ways to yield create some new value for clients and to reap some profit. A new public mandate can be seen as a type of resource that can be combined with, say private finance and/or human capital. And several of the reforms I looked at created some new public mandates – for example, for GPs in Britain to hold public budgets for the purchase of hospital and community services for their patients. Other reforms modified existing public mandates to allow for more entrepreneurial activity – for example, allowing social insurers in the Netherlands to engage in price and other forms of competition with each other even as they continued to act as carriers of compulsory public insurance.  Institutional entrepreneurs are likely to have their effects on the course of reform at different stages, depending on the political strategy of change. A big-bang, for example, means that they have to act quickly to secure “first-mover” advantage and position themselves for the future, while a “blueprint” allows institutional entrepreneurs to shape the reforms as they are in progress.

 What is the state of policy reform today?

The principal challenge is the volatility of the broad political arena. In three of the four countries covered in the book – the US, Britain, and the Netherlands – it is extremely unlikely that the strategies that each adopted at points in time in the past could be adopted today. A case in point is the failure of the Republicans in the US to comprehensively repeal the Affordable Care Act (ACA). The ACA was enacted by Democrats using a mosaic strategy of small-scale, fast-paced change. The Republicans, in turn, attempted a mosaic strategy to undo the ACA but failed to muster even an all-Republican consensus in the turbulence of the Trump era. Elsewhere, current Dutch politics does not allow for the kind of broad-based agreement that made possible a blueprint strategy. The British government is too dysfunctional and distracted by Brexit to undertake major policy change.) A Labour victory in the next British election, whenever it occurs, would however almost certainly lead to big-bang strategies of change in a number of policy areas, although large-scale change in health care has not been a Labour target under Corbyn.) Finally, in Canada, a second mandate for the Trudeau Liberals could set up the possibility of bursts of policy change in some arenas (of either the big-bang or the mosaic variety depending on the degree of provincial involvement), including action on some form of national pharmacare.

Finally, what is the one thing you want people to take away from your work?

Major policy changes in areas such as health care, with high political salience and/or large fiscal footprints, is a matter of high politics and strategic decision-making at the centre of government. Those who would seek policy reform need to be closely attuned to those politics, not only in order to identify and seize upon windows of opportunity when they occur but also to craft policy options that align with the likely strategy of scale and pace that central political actors will choose. Focusing only on the health care arena, or any other policy arena, will neither explain nor yield major policy change.

Carolyn Tuohy will discuss her book, Remaking Policy, in-depth at her book launch at the Munk School of Global Affairs and Public Policy on October 16. Register for this event on Eventbrite.

October 10, 2018