Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada (review)

Carolyn Hughes Tuohy, Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada. New York: Oxford University Press, 1999. 312 pp. $88.00 cloth.

How useful are the tools of political science in analyzing contemporary health policy? Comparativists, especially, are increasingly attempting to discover trends and patterns that can highlight common points of causality in the successful (or unsuccessful) formulation of health policy across states. But the problem, as Carolyn Hughes Tuohy notes, is the tension between the common and the particular; the more theoretical accounts, while rigorous in their causal explanations, often cannot be applied to a range of different contexts due to their exacting specificity. Yet accounts that attempt to recognize a variety of contexts thereby limit the causal utility of the theory by broadening their explanatory scope too widely. Tuohy's Accidental Logics can perhaps be seen as an endeavor to construct an account that combines the virtues of abstract theory with its causal force and historical narrative with its depth of detail. Its success in achieving the latter is unquestionable; its ability to accomplish the former is more arguable.

Tuohy points out, correctly, that familiar causal accounts focusing upon the nature of political institutions (Westminster, federalist, congressional) or upon political culture, policy legacies, public opinion, organized interests, or strategic judgment are useful in limited ways but fail in presenting a well-rounded, complex account of why health policy takes the form it does. Her task, then, is "to define a framework within which the intersection of these factors can be understood" (123). This framework is based essentially upon a systematic analysis of political institutions (broadly understood) within the wider context of a state's political economy and political culture. When a set of policy actors has both the political authority and the will to accomplish significant change, she argues, an episode of "policy change" occurs when major policy shifts (such as the postwar implementation of the National Health Service in Britain, or the establishment of national medicare in Canada) are possible. These "windows of opportunity," however, are relatively rare; in between are long periods of "path dependency" in which health policy is constrained by the "internal logic" of each individual state.

The richness and depth of the historical detail in this book are undeniable, and serve in and of useful guides to the nature of health care in each of the three countries. The narrative is, moreover, structured and organized in a very precise manner and focuses upon the particular combination of the "balance of influence" among types of actors, and the "mix of instruments" of social control in order to ascertain why particular windows of opportunity opened at certain times and not others. Specifically, she presents us with three puzzles: Why did such radical reform occur in Britain in the 1990s? Why did dramatic change in the health care arena occur in the United States in the 1990s despite no significant changes in public policy? And why, despite the strong fiscal pressure upon the Canadian health care system, has there been such remarkable stability throughout the 1990s? Here Tuohy is at her best, unraveling the threads of circumstance in each particular domain. Her densely detailed but masterful accounts of why the Clinton plan failed, for example, or of the logic of state-physician accommodation in Canada, are impressively wrought, with a wealth of variables disentangled to provide nuanced and multidimensional explanations.

Tuohy's work as an account of historical narrative, then, is a superlative scholarship, and one that health policy analysts will find extremely useful. But Tuohy's goals are more ambitious, as she wishes to provide a useful theorization of health policy formulation; it is here where one may perhaps take issue more vigorously with her account...