Dynamics Of A Changing Health Sphere: The United States, Britain, And Canada

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Abstract
PROLOGUE: Canada, the United Kingdom, and the United States represent three largely English-speaking countries that, in their varying forms, are models of contemporary democracy. But the ways in which their health care systems have evolved are quite different as a result of choices made at critical historical points. In this illuminating comparative study, Carolyn Tuohy, a political scientist and deputy provost of the University of Toronto, discusses the substantial differences that separate the nature of the three health care systems and the resulting logic that shaped them. She emphasizes that an important characteristic of these systems is the different ways in which they have structured the relationship between the medical profession and the state. Tuohy earned her doctorate in political science from Yale University. Her research pursuits have focused on comparative public policy, with an emphasis on social policy. This paper distills an argument presented in her most recent book, which was just published by Oxford University Press: Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada . Tuohy also has authored numerous journal articles and book chapters dealing with health and social policy, professional regulation, and comparative approaches in public policy. Different patterns of change in the American, British, and Canadian health care systems in the 1990s result from the particular logic of each system. Different balances of influence across major categories of actors, and different mixes of hierarchical, market-based, and collegial instruments have different implications for lines of accountability and for information costs, and thus create different incentives that shape behavior. Market instruments functioned differently when introduced into Britain's system of “hierarchical corporatism” than in the American mixed-market system. Profession/state accommodations in Britain and Canada tempered the pace of change, while the entrepreneurial logic of the U.S. system generated a turbulent transformation.