American health reform in comparative perspective: big bang, blueprint, or mosaic?

摘要

For comparative scholars of health policy, the enactment of the Patient Protection and Affordable Care Act (ACA) finally adds a contemporary American case to the set of episodes of major health policy reform. But is it the long-anticipated "big bang" of pathbreaking change? Is it yet another demonstration of failure to make such change? The answers to these questions demand a more nuanced understanding of change. An episode of "major" change in a health policy framework is one in which change is made on a large scale, at a rapid pace, or both. The scale of change relates to those elements that affect the capacity of key actors to achieve their ends: the balance of power across the state, private finance and health care providers (principally physicians), and the institutional rules of the game (in particular, the mix of hierarchy, market, and peer control). Large-scale or rapid changes in overall health care frameworks are rare, because they require extraordinarily favorable conjunctions of institutional and political conditions.