Institutional Change and the Health Politics of the 1990s

In the 1970s, Canada implemented its new health care financing system while the United States considered reform but failed to act. Reform debate in the 1990s must be informed by the correct lessons of the 1970s and an understanding of the subsequent changes in American government. The different Canadian and U.S. experiences had more to do with prevailing institutional arrangements than enduring societal characteristics. Since then, U.S. institutions—reflecting the way private power is represented and public authority is organized—have been dramatically transformed. These changes, along with the election of a president committed to reform, create a policy environment more conducive to health care reform than was true in the 1970s. The medical, insurance, and business alliance opposed to reform has been disrupted and lacks the means to prevail. Achieving reform remains a major challenge, but there is now an opportunity for bold policy action.