Carolyn Hughes Tuohy: Remaking Policy: Scale, Pace and Political Strategy in Health Care Reform

October 24, 2018 0:51:00
Kaltura Video

Carolyn Hughes Tuohy talks about her new book, Remaking Policy: Scale, Pace and Political Strategy in Health Care Reform (University of Toronto Press 2018). October, 2018.


Good morning I'm Scott Greer
professor of health management policy

global public health and
political science here at Michigan and

not the entertainment that you all came
for I'm only here to introduce Carolyn to

eat who has a biography and a little
high and out that you have sold just hit

a couple of highlights which for me are
some things you really all ought to read

starting with one of the best books you're
going to find on Canada which despite

being old is still very timely in
terms of capturing essential truths

moving on to this astonishingly
weird phenomenon accidental logics

it's a very good book which is one of
the few books by political scientists that

take the actual mechanics of health policy
and what people in the health system

think they're doing seriously gets out
of the comfort zone of legislators and

prime ministers and journalists what's
weird about it is that she wrote it while

parrot we're running much of one of
North America's largest universities so

how to do that is a question that
I'd like to have an answer to.

But what we're here today to discuss
is a still more ambitious new book

remaking policy you can see it here
you can see it here I recommend it.

Read it on a flight I

didn't once want to watch a movie
which is about all I can say.

So in addition to the 3 books Carolyn
is professor emeritus of political

science founding fellow and Public Policy
at the University of Toronto's monk School

of Global Affairs and Public Policy
degrees from Toronto and Yale and

among other things he is a Fellow
of the Royal Society of Canada.

Like I said there's more in the little
flyer that you have you didn't come to see

me so I'll take my props away and
hand the floor over to Mr Carroll into it.

Thank you thank you so much Scott for
that very generous introduction and

thank you for having the idea you and
Barry Rabe of having the idea of bringing

me here I'm very pleased to be here I'm
honored to be speaking in the Betty Ford

classroom I must say our 2 schools
have a history of collaboration and

it's just it's just a delight
to be here in person

I know that you came to hear about
American health care reform but

I did emphasize that it's in
comparative perspective so

you're going to get some real
comparative perspective here and

I'm going to confess at the outset
that it was not American health care

reform that intrigued me into
writing this book in the 1st place.

It was actually Dutch health care reform
that was the initial intriguing puzzle and

like many works of social science
this book does start with a puzzle.

So about 15 years ago

I did become intrigued with what the Dutch
were doing in health care reform.

Not so much actually by the content of the
reforms although that was interesting in

itself but by the process by which
they were brought about until 1980 S.

The Dutch had achieved
pretty universal coverage

health care coverage at
Community rates a K.

no penalties for preexisting conditions.

Through a mix of compulsory
social insurance for

the lower 2 thirds of
the income distribution and

voluntary private insurance for
the upper 3rd self regulated by

the insurers themselves all of
this under lane by undergirded

by a universal system of coverage for
chronic care.

Largely long term care well that worked
very well until the 1980s when under

the pressure of increasing health care
costs rapidly increasing health care costs

the self-regulatory model of the private
insurers began to fall apart and

we began to see things that
are familiar in the American context

the cream skimming of healthy patients the
dumping of risks into the public program

something had to happen in the 1986

a very dynamic prime minister Ruud Lubbers
established a commission to recommend

a new model that commission did in
a year recommend a new model which

would see all insurers placed on
a common platform formally private but

heavily regulated and
publicly subsidized That was the model and

looters actually managed
to build a consensus or

a consensus around that model.

The consensus also included an agreement
that the model would not be

adopted all at once upfront but
that it would be and

acted in stages and
acted not just implemented but

in acted the pieces would only be put
into legislation as the technical and

administrative capability was
developed primarily to manage the risk

selection that would that would be
part of the private insurance model

it took them longer than they anticipated
they initially thought this would take 5

years it ended up taking 20 there were
fits and starts along the way but

at the end of the day in 2006 they
adopted a model that corresponded

almost entirely to the rough outlines
of what had been sketched out 20 years

earlier now that is remarkable from
a political science perspective and

it's what intrigued me there was no
model in political science I think

it's fair to say that could explain
a reform that was neither a big bang

big change all at once or
a series of slow adhoc incriminates

that was the typical dichotomy in
political science the Dutch had

slowly moved over a long period in
stages to a system whose rough outline

had been agreed upon at the outset.

So I began thinking about how you could
understand that kind of change and

it led me to a model that I then
could see applying to a number

of other cases including
a number of American cases and so

that's what I'm going to be talking to you
about today you won't be hearing a whole

lot more from me about the Dutch Reform
you'll hear a little bit along the way but

I want to sketch out
the broad comparative picture

of health care reform within a new model
the process the politics of health care

reform within a new model and then situate
some American cases in that context

so the question is the question
that the book asks is when

do we see bursts of policy change.

Change that is of larger scale or faster
pace than the incremental norm or both.

My approach is to see these
strategies of scale and

pace as a question of politics
indeed as a question of high

politics at the center of
governments I have 10 cases

plus 2 that I go into
in somewhat less detail

in which there was a window of opportunity
for change I'll say more about how those

windows came about a window of opportunity
for policy change from the end of the 2nd

World War through to pretty much
the present in 4 countries the U.S.

the U.K. the Netherlands and
my own country of Canada

and I do this through
intensive case analysis hence.

The thickness of the book.

Would it would it be the case that I
could simply summarize in a number of

tables the evidence for this argument but
it does actually take going

into cases in some considerable
detail through 1st 2nd

reports etc and multiple interviews.

The argument I make that is that
in the normal course of events

policy cycling occurs
decision makers move back and

forth an emphasis within an established
repertoire within an established policy

framework more centralized less
centralized more regulated less

regulated higher spending lower spending
but essentially within the same model.

Periodic Leigh though there is there
are moments when it's possible to

move off that incremental path and
in those moments

to decisions to fundamental strategic
decisions have to be made how big and

how fast and
as I said those decisions in high

stakes areas like health care that
garner a lot of public attention or

that occupy a lot of the public budget or

In those areas these are questions for
the center of government for

what I call the high politics how
presidents prime ministers and

the people who advise them assess
their capacity to build coalitions

in the present but also to maintain

those coalitions to continue to have
influence in those coalitions over time.

So that's really the addition of this book
is to emphasize the importance of time

as a matter of strategic
decision in public policy making.

Before going into that further let
me just emphasize what I mean by

large scale change.

I mean changes in the law of decision
making whereby resources are allocated in

the system who decides on the allocation
of resources what is the balance of

influence in the system across
the state the medical profession and

private finance the 3 kill
pillars of the political arena

of health politics cross nationally
who decides what sanctions

how do they control each other what
sanctions do they wield against each other

can they command do they need
to exchange in a voluntary

market do they persuade through
appeals to common norms and

finally what legitimating principles
constrain their actions what

legitimates these decision making
processes what are the what

are the notions broadly accepted notions
of the basis of entitlement to health care

of the the obligations that citizens
have the appropriate role of the state

not just the weight of the state not just
the degree of influence of the state but

the role is a payer is an owner
is a regulator is a delegator

that policy logic is
fundamental to the character

of a health care system
spending can go up and down and

that's often experienced as
a significant change of course but

if those resources are flowing along
the same channels of decision making we

are not looking at fundamental
change in the system so

that's the way I define the scale of
change defining the pace of change I've

already signaled to you what I'm
interested in is the pace of enactment.

The pace at which these changes
get more or less hard wired

into legislation limiting
the discretion that those who implement

the policies can have it may even
establish timelines for implementation.

And the key strategic
question in terms of pace

the pace of an accident is whether
everything is done within a single

mandate of the initiating government or
whether a government is

risky and enough of a risk taker or
or brave enough or

confident enough in its own
persistence to actually

establish a timeline that will
extend beyond its current mandate

beyond the next election quite rare but
not impossible

I'm also interested in the book in
the pace of an act of implementation.

And I'll say a little bit more about
that not a lot in this talk but

I want to emphasize that the parameters
the fundamental parameters are set in

the enactment stage so
if we are impacts scale in pace we have

scientists will recognize the appeal of
these 4 quadrant models Well this is mind.

Scale and pace and
yielding 4 possibilities

a big bang redefining the institutional
logic in a single sweep.

Incremental series of disjointed
ad hoc steps to over time

these are familiar in the literature but

it's also possible to have large
scale slow paced legislative change

securing agreement on an up front
design to be gradually enacted.

And to fill out the picture it's
also possible to have a lot

of small changes as a result of
multiple deals all at once I

think of it as a kind of compressed
incremental ism into a very short period

of time which yields
what I call a mosaic so.

Let me take the 3 the 2 stages
of my model the 2 stages I'm

going to emphasize here
into into account and

talk 1st about the conditions for
opening a window of opportunity for

change before you even get to these
strategic decisions of scale and

pace what opens the window of
opportunity in the 1st place

a given set of political actors
a political party typically needs to be in

an institutional position that they
can actually mobilize a coalition.

In the case of health care
in overcoming the dense

population of vetoes potential
vetoes in the health care system

given the structure of interests you
need a very strong institutional

position you need a majority government
if you're in a Westminster system.

You need a supermajority in in the
American Congressional system typically.

And that needs to be backed
by an electoral endorsement

we'll see what happens when it's not
backed by an electoral endorsement

either a landslide election or
a set of successive reinforcements

so you have to be able to mobilize
opportunity authority that's

the opportunity what's the motive
the motive is that health care has to

form part of a broader agenda that
matters for partisan reasons.

In all of the cases I looked at there
was a strong partisan reason to

take on health care as a matter
of competitive advantage and

I'll give you a few examples of that so
I have 10 cases as I said

health policy change in windows of
opportunity in this period from the.

End of the 2nd World War through
to close to the present.

I have the founding

founding of the British National Health
Service the founding of Canadian

medicare universal physician
services insurance

the failed bigbang attempt of
the Clinton administration.

The US Medicare example will come back to.

The reforms under the English a coalition
of the Conservative Party and

the Liberal Democrat Party
in just a few years ago

New Labour's reform in the U.K. and
then 4 cases that I'm going to highlight

before getting back to the U.S.
cases the so-called internal market

reforms in Britain in the late 1989190.

Obamacare the Netherlands
reform I've already.

Signaled and one case from Canada
in 2004 I will go through these

fairly quickly but I want to do it
in order to sketch the landscape

into which I will then situate
some other American cases.

So the dominant logics in

each of the 4 cases that I'm
highlighting shifted in the U.K..

From a model in which
the state basically owned and

operated the health
care system to a model.

Initially called the internal market
in which providers and purchasers were

formally split from each other rather than
being in a hierarchy rather than having.

The allocation of resources determined
largely through budget lines that

flowed through a hierarchy purchases the
purchasers and providers were required to

formally contract with a negotiate with
each other and the state was somewhat more

formally distant in the US in the Dutch

case I've already described
the difference over time

in the US we move from
a system of employer based

grounded employer based insurance
with so-called residual programs for

the elderly in the poor
through to Universal or

near universal mandatory
insurance model with a gap filling

manage competition in the individual and
small group market in Canada pretty much

the old model is the new model in
Canada a very very stable for better or

worse model of a single payer physician
for single payer model for physician and

hospital services a mixed market for
all other services and that's

pretty much where we still are with a bit
more cross provincial variation spoke.

How did those changes come about
how do we map them on to these 4

strategic domains Why are these decisions
why are these strategies chosen and

as I've already signaled to you they're
chosen as a matter of politics as a matter

of political strategy regardless in fact
of what's going on in the health care

arena at any given time so where
leaders have consolidated authority but

face losing it relatively soon they
have a strong motivation to go big and

fast before the next election
before they lose power.

Typical in you would
expect in the Canadian and

British cases with the Westminster
system with competitive parties where

political decision makers have
to do a number of deals and

in all of these other quadrants they
they have to do a number of deals.

The only the only quadrant in which
a leader can basically command a BT and

says in the Westminster model Big Bang
model where they need to do a number of

deals there are a number of possibilities
as to whether they think they can maintain

about a 4 to over time and where they
think there is a fairly stable balance of

of of power they can do a blueprint
they can do what the Dutch did

everybody in the coalition believes that
they'll be somewhere around the table

as the next steps are taken as
the next pieces of legislation

are put in place and in the Netherlands
that is not only because of

a tradition of coalition government
although that certainly matters a lot.

It's also because they have a corporatist
decision making model in which the major

social partners are always around
the table so if the Labor Party for

example is not completely confident that
it is going to be within a coalition

within a governing coalition it knows that
anyway its proxies the labor movement

are going to be at the table so
all of the parties are relatively or

were were in them in the late
eighty's relatively confident

that they will be in some position of
power as the next steps are taken.

More likely it however is the case that
a lot of deals have to be made and at

least some of the members of the coalition
are pretty sure that there this is

their chance right that they're not going
to be in an ongoing position of power.

And in that case you want to do a whole
lot of small you want to grab what you can

do a lot of small deals all at once and
then finally and

this was something that only it emerged
for me anyway as I wrote the book

it's also possible that you could
have a minimum winning coalition

building there is a window for

the leaders think they might be an even
better position in the future and

in that case what you want to do is you
want to use your window of opportunity to

establish a platform on which you will
be well even better positioned to build

in the future and that in fact is what
we saw in Canada as well as in England.

OK Very quickly now yes
quickly I see the clock

I want to take you through the decision
tree in these 4 cases that

I'm highlighting the British
internal market reforms the Dutch

transition to universal mandatory
insurance Obamacare and the Canadian

continuation of incrementalism under what
was called the Health accord of 2004.

So here's the state here's the decision
tree which basically just tells you in

a different graphic what I've
already told you the hoops the story

the highlighted changes here
are simply what opens a window of

opportunity you've got motive and

The next question then is do you have
centralized control of your coalition

if you're a British or Canadian prime
minister the answer to that is yes

in a unitary if if you're only
talking about one level of government

I'm very conscious of that particularly
speaking to close up people.

But if you do control a coalition
of support what do you expect

about the your ability to maintain
that in the future Well if you are in

a liberal democracy you better count
on the chance that you will lose if you

have that level of consolidated authority
and you're not worried about losing it

you're probably not in a very democratic
system so this model is assuming

a liberal democracy in that case there
is only one route out of this box

it goes toward a potential law and
a big bang but

now let's see what happens
in each of our cases so

Here's Margaret Thatcher at the end of the

Majority government.

Strong electoral re indorsement But

Labor is nipping at the conservatives
heels particularly on health care and

they're looking to the $1092.00 election
and they do not as the British they want

to go into that election on
the back foot on health care and so

in 1989 Margaret Thatcher
establishes a small

Working Group chaired by
herself very few trusted

Cabinet colleagues to come up with
this internal market reform and

so how does this happen she has
the capability of mobilizing

authority to overcome vetoes Yes
she has centralized control at that

moment she did centralized control over
her coal of a coalition of support

she projects however even it came about
even faster than she thought it would for

herself personally a potential loss of.

Power and certainly the party was
looking at a potential loss of power

in the 1992 election and
they go for a big bang they

don't act at all at once and
implement it very rapidly

Ruud Lubbers in Holland I've
just talked about.

He also as I described has is
able to mobilize a coalition

of support he is in his 2nd mandate but

it's but that endorsement was important
because it was after a period of

volatility in Dutch politics so
he came in he was endorsed once he

was endorsed twice with a center right
coalition that was a significant really

Rian Doris meant he did not however have
centralized control of his coalition

by definition it was a coalition of
parties it was a center right coalition.

And but all of them could predict being in
a roughly similar position in the future

the sea the Christian Democrats Ruud
Lubbers party had been in somewhere

in the coalition in the Dutch government
either the Christian Democrats or

they're or their predecessors since 1918
they had never been out of government

it was reasonable for them to expect that
they would still be around the table.

And so they are able to implement
this blueprint reform OK.

In Canada Paul Martin comes into power

he takes he takes over within
the Liberal Party from him the previous

prime minister in 2003 at the time.

The media the political parties
including the conservative parties

were confident that this was the next
Liberal regime that this was that

there's been a vicious internal
competition between Martin and

Chretien Martin takes over The Economist
is the Economist newspaper is

telling us this is the next Liberal regime
what smartened going to do with it and

what he decided that he was going
to do with it was to continue to

distinguish himself as sharply as he could
from his predecessor his predecessor

had fairly fractious relations with the
provinces Martin decides I'm going to show

them I'm the guy who can deal with the
provinces takes them to the Grey Cup game

Anybody know the Grey Cup game the foot
good a Canadian in the crowd yes.

Big big football game in Canada so he
takes the one of his 1st acts is to take

a look Premier's to the Grey Cup game.

And they and he decides to make
health care or his his key

he's going to finally come to an agreement

with the provincial premier is after
a period in which federal funding has been

cut the federal government is
in the process of re investing

this is a window of opportunity
under anybody's definition.

But Martin decides that his best
approach is to use that window

too in the 1st instance by the goodwill
of the Premier's by closing

the funding gap that had developed
from the federal government and

then he'll build on it in the future but
he fully anticipated that he would

be in an even better position
having close that funding gap.

time in politics by the time we came

to the 2004 June 2004 election so
Martin takes over in November 2003

actually early December 2003 June 2004 is
an election and he's tipped into minority.

He's campaigned on health care he said a
meeting with the Premier is for September

it's all ready to go and he's tipped
into a minority government and then.

He decides he doesn't have a choice he
doesn't begin the stock with the end of

an incremental strategy I
asked him why you know why

didn't you then shift strategy
the Premier's were remarkably offering

some kind of deal on pharmacare on
extending drug coverage in Canada and

he said I just might the credibility of my
government rested on having that meeting

and getting a deal and I didn't have time
to do what it would take to negotiate

pharmacare deal with the Premier's
even if it was just a matter of months

we just didn't have time so there is
an incremental strategy the kind of

got stuck in or
constrained when political.

Conditions changed OK now this
is what you came for right so

we're into the American cases so how do
the American cases fit into this model.

So and the Obamacare case is
probably a classic mosaic.

You probably couldn't have a better
example of the kinds of political

calculations that go
into a mosaic strategy so

there is certainly a set
of actors willing to.

Enact change in health care as
a central matter of strategy

of of of an agenda in 2 senses it

Obama does make it central to
the economic recovery agenda but

it's also part of a Democratic
agenda of having.

And I remember at the time listening to
numerous colleagues and others who were

describing the end of a long Republican
arc that started with Reagan and

now you know now it's the end of that arc
and we're into another democratic art and

health care is central to that so and

for a brief shining moment with

a capacity to overcome
vetoes certainly however

not a centralized coalition
of support early attempts to

negotiate with Republicans fell apart as
you know and then the negotiations were

within the Democratic Party itself
numerous deals than the Louisiana Purchase

the you know Cornhusker Kickback
the whole set of deals.

That as the Democrats essentially raced
against what they knew was a closing

window to it to.

Come up with a deal which was in
fact a lot of changes relative to

each one of them relatively small all
at once feeling like a really big deal.

OK Let me take you through.

A few others of the America well I
guess all of the other of the American

cases in the book in somewhat
less detail than that

I had to reverse the orientation of
this decision tree but trust me it's

the same decision tree it just works like
to try to fit all these cases on and

I had to have to switch the orientation so
it's going right back to the New Deal.

We would trace it in this direction
was health care policy central

to the New Deal agenda Well sadly no.

There's lots of history as
to why that was the case.

Roosevelt F.D.R. came to.

A greater priority on health
care just before his death

actually but
it was not in the in the New Deal era.

As I say not time to get into
the reasons for that now so

it was essentially a continuation
of incremental ism.

However in 165-193-2009 extension 8
certainly was for

Lyndon Johnson for Bill Clinton and
for Barack Obama and

the parties at the time central to a
broader policy agenda were they capable of

mobilizing the necessary votes Johnson
having come in with a landslide.

Of super majority in
both houses of Congress.

More than 60 percent of the popular
vote I mean that was just a clear lens

slide electoral mandate.

In 2009 that was the that was the biggest
electoral mandate in both of those terms

in terms of control of the both houses and
the popular vote since the 1960 S.

for Obama.

In 993 this was an interesting case so
yes Clinton has.

The Democrats control both houses of
Congress not with a super majority.


But he comes in with 42 percent
plus of the popular vote

in that was a 3 candidate election.


There's a great quote in the book from
one of his advisors which who said

we we mis read change in the weather for

a change in the climate we thought it was
a change in the climate it was really just

a change in the weather and
they try to go for a big bang.

We can get in Question Period
we can get into so

why do I consider the Clinton reforms
a bigger bang the the Obamacare mosaic

I'm happy to address that but in
the interest of time I will motor through.

In any event they try for for a big
bang and it is a failure unfortunately.

So so then the just a trace
out through they do not have

a centralized coalition of support.


They think they have a centralized
coalition of support.

And they go for a big bang.

In the case of.

Lyndon Johnson and
the Democrats in 1965 they

have to do a number of
deals the medicare medicaid

mosaic as all call it which is essentially
a set of adjustments to the employer

based system is the result of deal making
within the Democratic congressional

leadership as Ted Marmor and
others have written nobody anticipated

that end result it was the result
of a series of negotiations.

In which all members of the coalition
were projecting a potential loss

of influence very similar to
the Obamacare music actually

And then fine no I guess I've
been through all of the cases.

Right the Clintons Yes OK So that that
is how I would map America's mosaic

mosaics in terms of this
decision tree now one more

yes one more case so the Republicans
attempt to repeal Obamacare.

Do Is it central to a broad
political agenda you better but.

Are they capable of mobilizing
the authority to overcome

the vetoes that they think so.

Do they have centralized control because
they control both houses of Congress and

the presidency.

Do they have centralized control
over their coalition of support

no they've got to do a lot of internal
deals just as the Democrats had to do

all sorts of internal deals to get it
through in the 1st place the Republicans

have to do internal deals
to try to repeal it.


They are facing a potential
loss of of influence

they try to do a mosaic
unpacking of a mosaic and

we know the result of that
one piece got got enacted.


Abolition of the tax penalties
enforcing the individual mandate.

OK a couple of points this I'm going to

just go through go I'm going to
address this slide very quickly

just to point out that these
strategies Good I've got 10 minutes OK.

These strategies matter because they
matter from both a policy point of view

and from a political point of view from
a pulp woops I'm blowing my cover here.

From a policy point of view they
the larger the scale the greater

the degree of coherence you can
achieve in policy you can ensure

that the various pieces that are supposed
to integrate actually integrate at least

in the design of the program if
not in the actual operation and

you may think coherence is a good thing or
you may nought there may be other things

that you prize in public policy but if
you think coherence is a good thing then

you might want to go for
a higher a larger scale.

On the politics.

Access And you notice I've
changed the names of these axes.

The the faster the pace

the greater the degree of conflict this
just leaps out from the cases in the book.

You try to do things really fast
in a field like health care and

you're compressing all of the vetoes into
us into a very narrow window of time

highly conflictual process now
it looks like high coherence

low conflict is a pretty
sweet place to be but

we see very very few examples
of that because of the rarity of

the conditions in which they're possible
in which governments actually project that

they're likely to be in a similar
position over time OK Now moving on.

Federalism complicate things further and
I told

Barry Rabe this morning that I thought
this should be the new logo for close up.

This indicates that all of these
strategic decisions strategic

assumptions and judgments that politicians
are making about their current and and

projected future positions of
influence are going on simultaneously

in different jurisdictions and
they're all in motion.

This really complicates things and

this is true in both of the federal
countries in my book Canada and

the US the the U.K.
as a sort of Quezon I fater federal

country and
we can get into that later if you want.

But essentially this this is the sort
of dynamic that characterizes the U.S.

and Canada what made the Canadian
the adoption of universal physician

services insurance in Canada
possible in this kind

of context was that
there was a this window

in which we were in a period of what was
called cooperative federalism in which all

of the provinces had an agenda of province
building some of them even more than

others but they were really focused on
Province building in the $1960.00 S.

and the carrot of federal funding was just

enough to bring them to the table and
the carrot and the stick

also of the federal imposition of a social
development tax on all citizens whether

their governments adopted the federal
framework for health care or not.

But generally speaking this
makes it even more difficult and

federal systems to to adopt change so.

Just drawing a couple of points from that
what does this say about the importance of

subnational jurisdictions as the
laboratories of policy change as sort of

little crucibles of in our not so
little crucibles of innovation.

The problem is that.

It may be the case that innovation that
has occurred at a sub national level

looks good for transplanting
to the to the national level.

Obviously Obamacare and the and
the Massachusetts Health Health Connector

that are a key case in point
The problem is that these dynamics have

been different these political dynamics
are different a are likely to have been

different at the sub national and national
level so you can't necessarily assume that

something that worked even something that
worked politically let alone on the ground

in health care at the subnational level
is going to work at the national level

or it can work the other way around as it
did in Canada Sisk out you on Canadian

province of Saskatchewan had adopted
universal health insurance in

see very very bitter physicians strike
defining communities and families.

By the time the national level does it
only a few years later a lot of the energy

has gone out of that conflict in part
because of the demonstration effect

of the Scotch one including the fact that
physician incomes went up not helped.

So so there's not a necessary replication
between the 2 levels of government

final thing I want to highlight is
the question of whether electoral cycles

are coincident or non coincident
national and subnational levels.

So if you have coincident
electoral cycles so

elections are going on federally and
at the state level at the same time.

You can have a kind of swamping effect
from the federal level that simply

washes over state level reforms and
we can see this in the case of

the attempts the commendable attempts in a
number of US states in the early ninety's

to adopt a blueprint reforms in
contexts of relative bipartisanship

within their legislatures and between
the legislatures and the governors.

They were they were agreements that
like the touch they were read and

write about the same time they were green
and so on the rough outlines of where they

wanted to get interesting Lee pieces
very similar to what ultimately

becomes the Affordable Care Act insurance
regulation Medicaid expansion some kind

of managed care for
insure insurance markets.

And these were on track
started before the $994.00

elections before the failure
of the Clinton plan and

then you get the Republican wave
in $94.00 that just washes over

the state legislatures even if they didn't
formally change hands the Republicans

gained strength in legislatures and
very often did take over the legislatures.

And essentially these blue print
pant blue prints were stalled or

in some cases repealed.

And finally.

You might think OK well maybe norm Cohen's
intellect troll cycles are better but

they have their own problems because what
that means is things are constantly and

change constantly and
change because some body somewhere is

facing an election in whatever
year you find yourself in and

in particular this was a problem for
John Chretien before Paul Martin

negotiated his 2004 health
accord with the provinces in his

predecessor had attempted did come up with
various health records which actually were

signed only by the federal government but
they were nonetheless called the courts.

And but they were but
it was in large part.

Partly because of courage and style but
largely because the provinces

themselves were facing elections over that
period and you had a number of Premier's

in Crete provinces who had taken over
within a given mandate from their

predecessors without having faced
the electorate themselves that was quite

an unusual circumstance but they were
really only willing to take any any risks.

And then another case would be Germany
which is one of the plus 2 that I

mentioned the plus 2 by the way where
the Republican repeal attempt and

the German case that I get
into in the conclusion.

In Germany where it was not
a matter of negotiations between

the federal government and the lander in
the States but rather the representation

of the lender within the structures of the
federal government because of the state

governments appoint the members of
the Upper House so what that did was

to really complicate the grand coalition
between the Christian Democrats and

the Social Democrats which might have
come up with health care reform there was

a window of opportunity might have
come up with health care reform.

But the there were 60 different
launder elections in a brief period

of time which meant that the composition
of the Upper House kept changing and

it was just very very difficult to come
up with with a deal so be careful what

you wish for non-coincidental electoral
cycles are not are not a lot better.

Or at all better I guess
than than coincident so.

Yes Just to summarize then the
non-coincidental electoral cycles make it

unlikely that a window of
opportunity will open and

they also complicate the choice
of strategy as in the German case

even when it does so thank you
very much if you want to know more

about the book before you buy it because
of course you're going to buy it but

if you want to check it out before
you buy it I have a companion site.

That will give you some chapter
summaries and general overview and

also some advice on if you're not really
going to read the whole book of course

I'll be devastated but if you're not
going to read the whole book you may

want some advice on how you read it
depending on your areas of interest so

I give you advice on if you're if you're
interested in welfare state reform but

not health care particularly Here's how
you might want to read the book etc There

are a number number of other ways and by
the way it is my hope that this framework

has relevance well beyond health care and
I mean that's that's actually

what would make me happy is to vote
about the book if it were picked up and

applied in cases other areas
other than health care but

we will leave you with health
care examples Thank you.