Editor's Note: Comparative Health Care Policy

At last year's annual meeting of the Academy for Health Services Research and Health Policy, I heard mention at one of the panels that there had been some debate over whether the Academy should sponsor sessions on comparative health care policy at future conferences. To readers of the Journal of Health Politics, Policy and Law, such a proposition would be most astonishing. As Mark V. Pauly and Chris Ham emphasize in the commentaries they have contributed to this issue, the health policies and practices of any particular nation derive from idiosyncratic roots and cannot be offered up as lessons one way or another for other countries without due consideration of their unique origins and contexts. Meaningful and reliable comparative analysis is a tricky business, to be sure. On the other hand, without careful examination of the empirical evidence from other health care systems, either in whole or in part, it is difficult to imagine how one can enhance the sophistication of policy analysis and elevate the quality of debate about alternative ways to organize and finance health care services. Wherever one resides, absent intelligently studied clues from abroad, one is left with nothing more than judgments about the status quo devoid of a standard of comparison, pure theory, or simple ideology.

It has always been a tradition of this journal to explore domains beyond our own shores as well as to evaluate the significance, when present, of American exceptionalism--to borrow a term from comparative political studies. Because of that tradition, we frequently receive manuscripts that explore health systems at various locations around the globe, either in the form of explicit cross-national comparisons of many states or more targeted country-specific analyses. Our routine business, with a little bit of nurturing, has generated the articles in this special issue on comparative health care policy. They do not cover a broad sweep of the world, or uniformly concentrate on a particular theme, or necessarily offer explicit lessons for the United States. They do help us understand what transpires elsewhere and why, and in one way or another reveal how we are different.

Taken together these articles and commentaries represent the marriage of themes frequently present in the pages of this journal--part of our comparative tradition. To introduce them, let me turn to the Victorian-era admonition for brides that their weddings include "something old, something new, something borrowed, something blue." The "something old" in this case is a fresh look by Charles H. Blake and Jessica R. Adolino at a subject of long and constant interest--the cross-national evaluation of the politics behind universal coverage. In "The Enactment of National Health Insurance: A Boolean Analysis of Twenty Advanced Industrial Countries," they test a number of propositions about the role of culture, institutions, and politics using a quantitative technique that overcomes the prevailing data limitations. The results both support the significance of institutional veto points and illuminate a variety of scenarios, with different mixes of attributes that open the door to enacting comprehensive reform. Culture, institutions, and politics are stacked against reform in the United States.

For "something new," we have an article on a country not previously examined in the journal and, following a majestic political transformation, new to the enterprise of furnishing all of its citizens entrée to health care services. Issues of coordination across levels of government in a rapidly changing political and institutional setting are central to Yogan Pillay's article, "The Impact of South Africa's New Constitution on the Organization of Health Services in the Post-Apartheid Era." The burdens the South Africans confront as they re-engineer both their governing institutions and their health care system blend challenges that are profoundly indigenous with those familiar to students of federalism and organizational complexity.

In "Medical Savings Accounts in Singapore: A Critical Inquiry," Michael Barr reexamines the original version of the most pronounced "something borrowed" in U.S. health care...