The fate of national health insurance in Canada and the United States: A multiple streams...

The United States is the only modern, industrialized country without some form of universal health care coverage.1 The failure of the most recent attempt to introduce universal coverage, Clinton's Health Security Act (HSA), spawned much speculation concerning why. Institutions (Marmor & Goldberg, 1995; Rosenau, 1994; Steinmo & Watts, 1995), ideology (Jacobs, 1995; Morone, 1995; Skocpol, 1996), class structure (Navarro, 1989), and interest groups (Laham, 1996; White, 1995; Wilson, 1996) are among the oft-cited explanations. However, individually they do not consider the dynamic and holistic nature of the policy process. For instance, if fragmented political institutions in the United States thwart attempts toward universal health care coverage, how can the passage of other sweeping legislation such as the Civil Rights Act of 1964 and the North American Free Trade Agreement (NAFTA) be explained? Likewise, ideology as a sole explanation is limited. How can America's acceptance of significant government intervention in education and environmental regulation be explained in light of a general distrust of other forms of massive government intervention, i.e., national health insurance? Similarly, an interest group or a class explanation cannot account for why the seemingly omnipotent American Medical Association (AMA) was unable to block the passage of Medicare, especially since the beneficiaries were the elderly and poor. Certainly, a more complex description of the policy process is necessary.

Kingdon's (1995) multiple streams (MS) provides a theoretical lens to analyze agenda setting and alternative specification, but it can be readily applied to the entire policy-formulation process (Zahariadis, 1995, pp. 33-34). MS assumes that governments are organized anarchies, and that three processes, or streams, drive the ascension of policy on the agenda and alternative specification. First, several problems exist within the purview of government, yet only a select few can be afforded serious consideration at any one time. Which problem makes it onto the governmental agenda is a function of significant changes in regularly reported indicators, crises, or focusing events, and policy feedback.

Second, existing juxtaposed to problems are solutions, which are identified and marketed by policy analysts, politicians, and academic researchers. Solutions are not necessarily created as a response to an existing problem, but in fact, are often a progenitor to problems. To be viable, solutions must be acceptable to the policy community such that they have technical feasibility (are doable), are affordable, and have value acceptability (are within constraints of values of the policy system).

The third stream is comprised of political variables including the national mood, interest group activity, and turnover in government. The national mood consists of public perception of an issue. Mostly, interest group activity affects policy through an oppositional role, blocking legislation, not promoting it (Kingdon, 1995, p. 42). Further, turnover in government, i.e., a new executive and/or legislative majority, often brings a new policy perspective and a window of opportunity for action for policy entrepreneurs.

When there is a confluence of streams, a window of opportunity is opened. Sometimes the opening of one policy window can lead to spillover. For instance, if a principle of government intervention in health care is established through protection of certain groups, e.g., the elderly and poor, this might precipitate even more government involvement in health care.

The MS lens is employed here to examine problems, politics, and policy solutions as they evolved and interacted leading to the passage of national health insurance in Canada and the last failure of reform in the United States, 1993-94. A comparison of these cases is intriguing for several reasons. First, both countries did not develop national health insurance in the first half of the 20th century, a period when most industrialized countries had adopted some form of universal health care. Second, there are many sociopolitical similarities. Relatively speaking, they have similar political cultures, along with significant ethnic diversity; equivalent socioeconomic development; relatively weak labor unions; and comparatively weaker social democratic parties (Lipset, 1990; Maioni, 1997; Rosenau, 1994; Smith, 1995). On the other hand, there are important differences in political institutions concerning legislative-executive relations and different forms of federalism, which weaken these similarities. For instance, while Canada is generally considered to have weaker social democratic movements, they are stronger than in the United States, because parliamentary governments are more amenable to the rise of third parties (Maioni, 1997). This is an important factor in explaining the eventual passage of national health insurance in Canada.

A major criticism of MS is the inadequate attention to institutions (Sabatier, 1996; Schalger, 1999). This study refines MS by paying particular attention to political structure. There are many institutional differences between Canada and the United States. Regarding legislative-executive relations, the political structure within the United States is based upon a separation of powers between the executive and legislative branches, whereas in Canada's parliamentary system, there is a fusion of these powers. Largely due to the separation of powers between the executive and legislative branches, political parties in the United States are comparatively weak, particularly between the branches of government (Nice & Fredrickson, 1995; Rosenau, 1994). Canada's parliamentary system, which fuses executive and legislative powers, encourages stronger party ties (Rosenau, 1994; Taylor, 1990). In the United States the separation of power creates several veto points, at which government actors can pressure the blockage of legislation. At these veto points, substantial mobilization is necessary to circumvent entrenched interests (True, Jones, & Baumgartner, 1999). In the Canadian system, majority governments are generally able to formulate policy despite legislative opposition, if there is no broad public dissent.

While Canada has a more centralized system of decisionmaking at the national level, its federal structure is more decentralized. The federal government is less a breeding ground for national policy as it is a "meeting place for regional and cultural factions to work out their differences" (Gillroy,. 1999, p. 370). Also, Maioni (1997) argues that Canadian federalism facilitates the election of third party governments at the provincial level, which as seen here, has an important role in policy innovation and diffusion. State governments in the United States do not have the same independence and constitutional authority in certain policy areas, such as health care, as do Canadian provinces (Maioni, 1997).

Political structure affects MS in several ways. In a federal system of government problems, politics and solutions at the subnational level may affect problems and solutions at the national level and vice-versa. Also, a presidential system is generally less responsive to quick, drastic policy changes because of its several veto points. A parliamentary system, with a fusion of legislative-- executive relations, is more tenable to quick, significant change, so a shorter duration for a policy window is sufficient. Therefore, the window of opportunity needs to be larger and/or longer for a presidential system than for a parliamentary system. Therefore, a new hypothesis (H:4) for MS is considered along with the traditional hypotheses in MS. The additional hypothesis accounts for the role of political structure.

H1: Problems will only make the governmental agenda if there are widely accepted indicators reporting worsening conditions and/or a crisis/focusing event.

H:2 In order for solutions to be attached to problems, they must have technical feasibility and value acceptability.

H:3 In order for the political environment to be conducive to policy formulation, there must be a supportive national mood, acquiescence from key interest groups, and entrepreneurship by key governmental actors.

H:4 Political structure affects how long and large a window of opportunity is necessary for policy change.

H:5 Passage of policy depends upon problems being identified, the availability of an acceptable solution, and a conducive political environment.

This article contributes both to the development of the MS lens and subsequently a better understanding of the complexity of major health reform in the United States and Canada. First, it tests propositions derived from an emerging theoretical lens (Sabatier, 1999). Mayer (1989, p. 47) notes that research needs to be "cumulative," and that the testing of existing theory is imperative "for expanding the corpus of what we can say that we know." Second, since MS is based upon the assumption that democratic governments are organized anarchies, it must be employed across democratic political systems and across time. Third, including a hypothesis of the effect of political structure on the MS lens provides a necessary refinement of MS if it is to be used comparatively. Fourth, it shows how the MS lens can be used to incorporate traditional theories into a more complex understanding of why the United States does not have national health insurance.

In the following sections, the Canadian experience with national health insurance is explored first, followed by the United States. In both cases organization is structured around a discussion of each of the three streams separately and followed by a consideration of spillover and policy windows. The conclusion provides a comparison of the streams in both countries and a placement of these findings within a theoretical context.

Merging Streams: The Canadian Experience

National health insurance found a home in the Liberal party platform of 1919, but fiscal conservatism and provincial autonomy impeded serious attempts toward national health insurance. In 1947, Saskatchewan adopted a provincial hospital insurance plan. By 1961, all provinces were participating in the Hospital Insurance and Diagnostic Services Act (HIDSA), which provided for national hospital health insurance. In 1962, Saskatchewan led the way again with the passage of a provincial medical insurance plan, followed in 1966 by the Medical Care Act, providing for national health insurance. The question, then, is why did Canada finally adopt national health insurance at this time?

Defining a Problem

Regularly reported indicators, crises/focusing events, and policy feedback drive the problem stream. In the early 1960s, all of these factors were evident in Canada. With respect to indicators, the commissioning of a study on health played a large role in providing information that would eventually have a strong impact in the problem stream. Responding to pressure from the popular Saskatchewan experience with universal insurance and the recommendation of the Canadian Medical Association (CMA), which was hoping to slow down and control the debate over health care, the Conservative government appointed a Royal Commission to study and make recommendations regarding health care conditions. The findings of the Hall Report were instrumental in propelling health care onto the agenda. Concerning access, the Royal Commission reported that over 41.2% of Canadians did not have any type of medical care insurance.2 Of the less than 60% that did, the adequacy of their insurance was questionable (Royal Commission on Health Services, 1964, pp. 727-731).

There were other conditions, in the form of policy feedback, shaping the problem stream. The passage of the HIDSA provided for national hospital insurance. The HIDSA had the unintended consequence of creating an incentive for consumers and providers to use more expensive hospital care in order to ensure payment (Weller & Manga, 1983, p. 229). Further, as discussed below, the HIDSA led to an important spillover.

Equally, if not more compelling, was a focusing event in Saskatchewan. After Saskatchewan implemented medical care insurance in 1962, physicians within the province went on strike in protest. On July 1, physicians in Saskatchewan refused to provide any services, except emergency care. Such a risky and provocative strategy by the doctors led to a firestorm of bad press, even from media organizations that had historically been sympathetic to the concerns of the physicians (Naylor, 1986, pp. 207-208; Taylor, 1978, pp. 311-314). The strike lasted over 3 weeks, giving the media ample opportunity to discuss the issue nationwide and for resentment against physicians to increase (Kinch, 1995, pp. 209-210; LeClair, 1975, p. 18). Eventually the strike ended, and the Saskatchewan medical insurance program survived. The strike, ironically, turned out to be a focusing event as it directed public attention toward the issue of national health insurance (Weller & Manga, 1983, p. 230).

An Acceptable Solution

Ideas and proposals in the policy stream rise and fall over the years, and are molded by competing proposals. For solutions to have credibility, they must have technical feasibility, be affordable, and have value acceptability. In Canada the idea of national health insurance was for decades a solution in search of a window of opportunity. The appointment of the Royal Commission on Health Services was a watershed event in the policy stream. Emmett Hall chaired the Commission that was appointed by the Conservative Diefenbaker government. The composition of the Commission, which heavily represented medical interests, led many to believe that the Commission's recommendations would represent the medical community (Taylor, 1978, p. 342).

The program for national medical insurance that passed in 1966 resembled to a large extent the principles embodied in the Commission's Final Report. These recommendations had likewise greatly resembled the HIDSA and the Saskatchewan medical insurance plan. The main concern for the provinces was their autonomy. Any plan had to represent this concern. The Hall Commission's recommendations provided for a federally financed insurance scheme, with provincial administration. The provinces were expected to provide insurance plans that were comprehensive in benefits, with the federal government supporting 50% of the costs (Royal Commission on Health Services, 1964). Given that the recommendations from the Final Report were rooted in existing policy, drafted by members from key interests within the health policy community, and sensitive to provincial autonomy, the solution reflected the established values of several, but certainly not all, interests within the policy system. The ensuing debate centered on the values of government-sponsored health care versus free enterprise supported by the medical profession and insurance industry. Indeed, the physician strike in Saskatchewan clearly demarcated the different values. Technical feasibility was less an issue, since national hospital insurance had proven workable and universal medical insurance had been modeled in Saskatchewan.

The Final Report disappointed and dismayed the CMA, which supported a voluntary scheme providing coverage through government subsidies. The Commission rejected subsidization for issues of technical feasibility noting that the number of people who would require subsidy to meet total health services costs is so large that no government could impose the means test procedure on so many citizens, or would be justified in establishing a system requiring so much unnecessary administration. (Taylor, 1978, p. 346)

Additionally, a subsidized plan was projected to be more expensive than other alternatives. The CMA interests in the report were also hurt when a potential advocate, Wallace McCutcheon, an economist who represented business, resigned from the Commission before the Final Report's publication (LaMarsh, 1968, p. 120).

The solution of national health insurance had waited for the opportunity to rise to the top of the policy stream. Yet, it was events in the political and problem streams, and the opening of a window of opportunity, that allowed for policy entrepreneurs to push it through the federal government.

Changing Political Conditions

Organized anarchies have fluid participation. Decisionmakers come and go, and when certain actors are present, change is likely. In the development of Canadian national health insurance, turnover in party leadership positions and party composition in Parliament were critical in forging the political stream.

In 1957 the Liberal party lost control of Parliament to the Conservatives. In response to losing control of parliament, new Liberal leadership was elected. Lester Pearson and progressive forces seized control of the Liberal party. In 1963, Pearson led the Liberal party back into control of the Parliament, albeit in a minority government.

Key appointments in the Pearson Cabinet led to policy entrepreneurship. Pearson appointed Judy LaMarsh as Minister of Health and Welfare. LaMarsh was particularly committed to national health insurance, because she had seen, in the illnesses of her mother and grandmother, the devastating financial toll of longterm illnesses (LaMarsh, 1968, p. 121). On the night Pearson requested that she be Minister of Health and Welfare, he remarked that she would have to "fight the Minister of Finance" for money for the pension and national health insurance programs. She reflected, "It flashed through my mind at the time that considering the extent of Walter Gordon's (the new Minister of Finance) commitment to these programs...that fight wouldn't be too tough" (LaMarsh, 1968, p. 47). In previous Liberal governments, Ministers of Health and Welfare who were committed to national health insurance had to tangle with Ministers of Finance unsupportive of national health insurance (Taylor, 1990, p. 142). LaMarsh and Gordon's entrepreneurship was instrumental in crafting the national health insurance bill and providing the political momentum for it in 1966. Interestingly, Gordon's replacement at Finance, Mitchell Sharp, an opponent of the bill, was able to delay the actual implementation a full year, with Pearson's approval, because of the government's worsening financial situation (Pearson, 1975, p. 227). Had Sharp been Minister of Finance in 1963, there might not have been a national health insurance bill in 1966.

The New Democratic Party (NDP) party, which evolved from the union of Cooperative Commonwealth Federation (CCF) and labor, was gaining power at the federal level. The NDP, a social democratic third party, was a champion of national health insurance. It was a CCF government in Saskatchewan that originally brought compulsory medical insurance into Canada. After the 1963 election, the NDP represented the "balance of power" in the Parliament for the shaky Liberal minority government (Maioni, 1997, p. 417).

Also in the political stream, the CMA was strongly against any plan that would affect the traditional fee-for-service financing scheme. However, the public relations disaster in the Saskatchewan strike hurt the CMA's attempt to extinguish the spark for national health insurance. In one of the more infamous stories concerning the strike, the New York Times reported that a 9-month-old baby died on the first day of the strike, purportedly because his parents had to drive to a variety of locations looking for physician services (Badgley & Wolfe, 1967, p. 61). While events in the political and problem streams provided the immediate impetus for the opening of a window of opportunity, the foundation for change evolved slowly through time as the result of spillover.

Spillover and Opening a Policy Window

Spillover is the process by which change through the opening of one policy window sets a precedent facilitating change for the opening of another window. In this case, spillover consisted of a gradual acceptance by provincial governments of national financing of health care. While health care was historically the domain of provincial governments, the principle of provincial autonomy in health care began to erode after the Depression. As a result of the federal-provincial conference immediately after WWII, a principle was set when the provinces accepted a cost-sharing plan from the government for the planning and construction of hospitals (Vayda, Evans, & Mindell, 1979, p. 219; Weller & Manga, 1983, pp. 226-227). The adoption of HIDSA significantly strengthened this principle (Crust, 1997, p. 21) and was central to the process of spillover and therefore merits attention here.

Government-sponsored hospital insurance began at the provincial level. Saskatchewan was the first province to adopt compulsory hospital insurance. Therefore, it is important to show that the MS lens describes how compulsory hospital insurance evolved in Saskatchewan, and then how the principle of government-sponsored hospital insurance in Saskatchewan led to spillover at the national level with the passage of the HIDSA.

With respect to problems, Saskatchewan had been particularly hard hit by the Great Depression. A sole reliance on a grain economy led to a boom-bust cycle, with mostly bust during the Depression. The Depression had reduced the ability of traditional funders of hospital care, e.g., municipal government, religious groups, and private contributions, to keep up with the increasing cost of hospital care (Vayda & Deber, 1992, p. 127).

The political stream was also driven by the devastating impact of the Depression. Badgley and Wolfe (1967, p. 4) argue that the populace, devastated by the misery of the Depression, developed a sense of entitlement for social services (without means testing). Turnover in the political machinery also occurred. The CCF captured the Saskatchewan government in 1944. The CCF had a clear goal toward complete socialized medical services (LeClair, 1975). Opposition from the medical profession was limited, because many physicians felt that such a plan would help them receive payment for services and generally did not affect their position (Badgley & Wolfe, 1967).

Concerning solutions, the Saskatchewan plan for compulsory hospital insurance "was probably the most dramatic health policy innovation in North America to date" (Weller & Manga, 1983, p. 227). It could be argued that it was merely a natural extension of health plans already in place within rural communities. Some rural municipalities were already paying for the services of doctors via general taxation and funding hospital construction.

Once the Depression hit, falling tax revenues eviscerated such plans. Consequently, the Depression served as the window of opportunity for the CCF government. The ubiquitous economic impact of the Depression, an increasing acceptance of government intervention in health care, and a weak opposition from potential opposition, all led to the passage of provincial hospital insurance in 1947. Soon after, three other provinces set up similar schemes.

The hospital insurance plans were quite popular. As such, most provinces began to actually pressure the federal government to adopt the national hospital insurance plan as a way to help financing (Vayda et al., 1979). Provinces were in the position of having to convince the national government to pass a national hospital plan. In 1948, Louis St. Laurent was elected prime minister. While his Liberal party had always supported the idea of national hospital insurance, St. Laurent, a former corporate lawyer with a strong predilection toward market-oriented solutions to social problems, was not enthused about a national hospital plan.

At the 1955 federal-provincial conference in April of 1955, provincial premiers pressured a politically weakened St. Laurent to put the issue of national hospital insurance on the agenda of the conference. Further, Health and Welfare Minister Paul Martin, a supporter of national hospital insurance, threatened to resign if St. Laurent remained opposed to its consideration. At the commencement of the conference, St. Laurent appointed a study committee comprised of representatives from his cabinet and provincial governments to consider the costs and benefits of hospital insurance. As the problem stream and policy streams were moving toward passage, the political stream merged in 1957 when the HIDSA was passed unanimously. There was strong opposition from expected sources (industry and commerce), but the CMA was not stridently opposed, even though it did not support the final legislation (Taylor, 1990, pp. 82-- 95).

The abatement of the barrier of provincial omnipotence in health care, first with hospital construction grants and later with the HIDSA, was critical in establishing an acceptance of federal intervention in providing medical insurance. With this principle established, the streams were able to merge for the passage of medical insurance in 1966. However, when the plan was implemented in 1968, only two provinces were on board. By 1972 all provinces were on board. Largely their acquiescence was due to pressure to pass a popular plan. In Quebec, for instance, the Toronto Daily Star editorialized that thousands of "Canadians may suffer preventable, and untreatable disease.. because of the Quebec government's insistence on maintaining its precious autonomy" (Schwartz, 1974, p. 304). In the end, after almost 50 years from first being adopted as a platform of the Liberal party, national health insurance had come to Canada. South of the border, different currents in the three streams were shaping the fate of national health insurance.

Parallel Streams: The United States and National Health Insurance

The United States flirted with national health insurance several times in the first half of the century. Passage of Medicare and Medicaid significantly increased government provision of health insurance in the 1960s to the elderly and the indigent. During the Bush administration and the 1992 presidential campaign, national health insurance once again received serious consideration. Why did national health insurance fail at this time?

A Divided Problem Stream

In the late 1980s and early 1990s, evidence was building that health care conditions in the United States were worsening, particularly with respect to cost and access to insurance. A 1992 report on the status of health care in the United States noted "almost unanimous sentiment that the U.S. health-care financing system is unsatisfactory, and there are disturbing trends that it may be unsustainable" (Organization for Economic Cooperation and Development, 1992, p. 41). In the 1980s, medical-specific inflation increased at an annual rate of 2.7%. Most other modern industrialized countries experienced medical-specific inflation at a much lower rate (Organization for Economic Cooperation and Development, 1993, p .24). A 1992 Kaiser/Commonwealth Insurance survey reflected growing concern with cost, as Americans listed cost as their number one health concern (Walden, 1995, p. 160).

Higher costs were pinching many groups. Large companies that provided health insurance to employees were frustrated at the increasingly expensive benefit of health insurance. From 1970 to 1990, health care costs for businesses increased from 3% to 7% of total compensation (Organization for Economic Cooperation and Development, 1992, p .56). Labor was concerned that higher health care costs being absorbed by employers were leading to higher-cost sharing for workers and lower wages. Policy feedback was also shaping the problems streams, because state governments were feeling the effect of higher costs on their Medicaid budgets. The federal government also found Medicare costs rapidly increasing (Hacker, 1997; Rovner, 1995).

Devoting a significantly higher percentage of its gross domestic product (GDP) to health care did not in itself cause alarm. As a whole, higher costs were not translating into better access and quality of care. It was estimated that roughly 14% of the U.S. population (31-36 million) was without health insurance (Schieber, Poullier, & Greenwald, 1991, p. 12). Roughly 20 million Americans were underinsured, bringing the total of under/uninsured to over 54 million people (Pepper Commission, 1990, p. 23). There were also concerns about the quality of health care in the United States. The United States had the highest infant mortality of the 24 Organization for Economic Cooperation and Development (OECD) nations except for Portugal, Greece, and Turkey.

Despite these indicators, it was a special election for a vacated Senate seat in Pennsylvania that propelled the issue on the national agenda (Hacker, 1997; Laham, 1996; Skocpol, 1996). In 1991, Democrat Harris Wofford was appointed to temporarily fill the Senate seat left open by the untimely death of Republican Senator John Heinz. Many considered that the special election would go to Republican Richard Thornburgh. In a surprising turn of events, Wofford won the election. Through polling, Wofford's campaign team had stumbled across a deep concern for health care among voters in Pennsylvania. Consequently, they pushed the issue hard during the campaign. Since the election in Pennsylvania came during an off year and 1 year before the next presidential election, it received considerable attention and became a focusing event.

There was a sense that the health care system had many problems and perhaps was in a state of crisis, but the problem stream was divided. First, while health care indicators emphasized problems in access to health insurance for 14% of the population, 86% of the population had health insurance. Consequently, access problems in the United States were for a much smaller percentage of the population. Heclo (1996, p. 26) argues that those without health insurance "posed the classic problem of collective action by a poorly organized, non-affluent body of people." Poor quality of health was found primarily in lower income and minority groups. Infant mortality rates were 230% higher for Blacks than Whites (Weiss, 1997, p. 16). Second, events in the problem stream are shaped by budgetary constraints (Kingdom 1995). In the early 1990s, the most salient issue facing government was the increasing federal debt.

An Unacceptable Solution

Finding sustained consensus in the policy stream proved unattainable for Clinton. The legacy of past defeats of national health insurance lingered and precluded value acceptability. During previous battles, its opponents had effectively attached the label of "socialized medicine" to national health insurance. Given this environment, any form of national health insurance had to elude such negative perceptions. This proved impossible for Clinton, as America's underlying antistatist ideology provided a deep well for opposition in raising concerns about increasing the role of big government in health care (Skocpol, 1996, pp. 133-172).

It could also be argued that Clinton's plan lacked technical feasibility. By attempting to reform the entire system, Clinton was in essence trying to restructure one-seventh of the economy. Such a monumental change is wrought with technical problems, such as what would be the role of private insurance companies. Also, Clinton's plan did not meet the test of being budget neutral. According to the Congressional Budget Office, savings from cost controls would have been consumed by extending coverage, and as a matter of fact, additional funds would have been required (Aaron, 1996).3

Eventually, managed competition within a budget became the foundation of Clinton's HSA. Hacker (1997) and Davidson (1995) argue that Clinton's solution was flawed in that it represented Clinton's reliance on policy analysis in an attempt to achieve political compromise, which was a poor strategy with a plan lacking value and technical feasibility. The process of alternative specification became the focus of the Clinton administration with little regard for strategy in the decisionmaking process.

A Shallow Political Stream

Wofford's victory over Thornburgh and the election of Democrat Bill Clinton indicated that the political stream might be responsive to coupling. Winning only 43% of the popular vote, Clinton's victory appeared more a repudiation of Bush. Furthermore, Clinton's victory was not paralleled with significant electoral success for the Democrats in Congress.

In considering Canada, certain policy entrepreneurs were critical in shaping national health insurance and expediting its passage (e.g., LaMarsh and Gordon) in the Pearson government in Canada. Clinton, on the other hand, suffered a tremendous setback when a key actor, House Ways and Means Chairman Dan Rostenkowski, was forced to step down because of charges of misuse of congressional and campaign funds. Once Rostenkowski stepped down, Clinton had no powerful champion in the House, and reform consensus was severely hindered.

The landscape of interest group politics had changed significantly since the last time national health insurance had been debated. By 1990, the AMA was no longer omnipotent in health policy. In the newly emerging policy network, new actors, such as congressional staff, academic researchers, and nonprofit health providers, have a much larger influence on health policy (Peterson, 1994). Indeed the AMA participated in the development of strategies for national health insurance coming up with its own plan, Health Access America. The AMA was not the only interest group that initially rallied behind the idea of national health insurance. The American Hospital Association, the Pharmaceutical Manufacturers Association, the Health Insurance Association of American (HIAA), and large businesses (represented by the Business Roundtable, the National Association of Manufacturers, and the U.S. Chamber of Commerce) all originally worked to shape a national health insurance plan that they felt was inevitable.

Nevertheless, there was stiff opposition to reform from other interests. For instance, the National Federation of Independent Businesses (NFIB) proved to be a worthy opponent of any employer mandate to finance national health insurance. They sought out "gettable" legislators. For instance, powerful proponent John Dingell, Chairman of the Energy and Commerce Committee, was unable to get national health insurance out of his committee. Swing votes on his committee, such as Kansas Democrat Jim Slattery, were heavily lobbied, both in Washington and in their district by the NFIB. Similarly, the HIAA, which originally supported national health insurance, became an opponent when the Clinton plan called for a regulation of insurance rates. Its infamous "Harry and Louise" television ads depicted a middle-class couple lamenting over the complexity and restrictiveness of the Clinton plan. The ad quickly became the centerpiece of media coverage of the debate (Scarlett, 1994). The NFIB and HIAA showed that because of the many veto points in American politics, a strong and willful interest could have a profound impact (Headden, 1994; Johnson & Broder, 1996).

Limited Spillover and a Closed Window?

In Canada, spillover was an important piece of the puzzle. Was spillover evident in the case of the United States? The answer is somewhat complicated. The passage of Medicare and Medicaid established the principle of national involvement in the financing of health care, albeit for only two target groups, the elderly and indigent, and not a cross section of Americans

Another important spillover occurred in Canada when certain provinces established universal hospital insurance, which was then the impetus for a subsequent federal plan. The same process occurred with respect to medical insurance. In the 1980s and early 1990s, state governments in the United States were facing essentially the same conditions driving the problem stream at the federal level. In several states the political streams were moving toward universal health coverage for their residents. In the policy stream an eclectic assortment of solutions was considered and implemented. Hawaii, in fact, had passed nearuniversal health insurance roughly two decades earlier. In 1993 Washington State passed a health reform package far more reaching than any other state and resembling the Clinton plan, but the plan was repealed a few years later. Oregon further pushed the frontiers of innovation with its plan to increase the number of people eligible for Medicaid using rationing as a tool for keeping costs in check. Several other states also enacted plans in the early 1990s intended to broaden the number of people under the umbrella of state-sponsored health insurance.

Why did state innovations in the United States not also lead to spillover at the federal level, as was the case in Canada? The answer largely lies within the differing frameworks of federalism. In Canada, the decentralized structure, coupled with the strong tradition of provincial autonomy in health care, allowed provinces to create policy unencumbered by federal restrictions, and then provinces could pressure the federal government for fiscal support. In the centralized structure in the United States, the sharing of responsibility for health care frustrated reforms at both levels. Major reform at the federal level was complicated by the state purview over insurance regulation and licensing of health care providers. On the other hand, federal obstacles limited states. The Employer Retirement Income and Security Act (ERISA) preempted states from regulating or taxing employer health funds. According to Rodgers (1995), all states seeking health reform had problems dealing with the limitations of ERISA. Further, Medicare, which represents around 40% of health spending, is not controllable by states. This restricted state flexibility in drafting health reform.

Conclusion: Comparing the Streams

An analysis of the cases along the MS framework is compared systematically in Table 1. A measurement of variables in the three streams illuminates key differences that help describe the varying fates of national health insurance during the two time periods. Nevertheless, such an analysis is clearly limited by the nature of the MS framework. First, since the MS framework is designed for description over prediction, it is inclusive of several variables for which concrete measurement is difficult. Second, it is based on the premise that policymaking is often the fate of random, unpredictable events. Its application is prone to problems of ex post facto analysis, which can lead to a skewing of data to fit the framework. Within these conditions of the MS framework, it is still possible to provide measures that are replicable and refutable. Nevertheless, subjectivity is undeniably inherent in the operationalization, measurement, and interpretation of the variables.

In the following section each variable is operationalized and interpreted (based upon the case studies) with summary results provided in Table 1. The summarization of each variable within the three streams is based upon a crudely specified scale: Strong = clear and strong evidence that this variable supports the opening of a window of opportunity; Medium = some evidence that this variable supports, or at least does not inhibit, the opening of a window of opportunity; Weak = little to no evidence that this variable supports the opening of a window of opportunity.

The operationalization of each of the nine variables closely mirrors Kingdon (1995), with some slight modifications. Indicators, focusing events, and policy feedback measure the problem stream. Most indicators within health care are embedded within one of three critical areas; cost, access, or quality. According to Kingdom routine monitoring or special studies of indicators are important for assessing how a condition is changing, but whether or not conditions become a problem is left up to interpretation. Through analysis based on interpretations of politicians, the media, policy analysts, and key interest groups, it is generally clear whether or not a condition will be considered a problem. In the case of Canada, the highly respected study by the Hall Commission provided ample evidence that there were problems both with quality of health care and especially with access to medical insurance across a large percentage of the population. Further, cost was a problem, because the HIDSA encouraged people without medical insurance to seek costly hospital care. In the United States, the case analysis showed a growing consensus that indicators concerning cost and access were suggestive of an impending crisis. However, concerns about cost and access were not complimentary, because not all politicians and interest groups were equally concerned with each. Corporate and medical industry interests were most concerned with cost, not access, whereas certain citizen groups and some more liberal-minded politicians were more concerned with access. Different interests demanding different interpretations of the problems within health care divided the problem stream.

Operationalization of a focusing event entails analyzing whether or not there was a crisis or event that galvanized the attention of the political system, the media, and the public around the issue. In both cases, it is clear that there were focusing events. In the case of Canada the physician's strike in Saskatchewan after the passage of medical insurance was an event that propelled the issue onto the national agenda. In the United States, the Wofford Senate election victory also acted as a focusing event, thrusting national health insurance onto the 1992 election agenda.

Policy feedback is also evident in both cases. In Canada, the HIDSA was a popular policy, thus increasing support for expansion of government-provided health financing. On the other hand, there was also negative feedback, because Canadians without medical insurance reportedly used expensive hospital insurance for health care. In the United States, policy feedback was largely negative, in that cost shifting was leading to a greater reliance on Medicare and Medicaid, greatly increasing the costs of these programs. Such expenditures were particularly onerous in times of federal and state budget deficits.

In the policy stream, Kingdon refers to many factors that affect the ability of a solution to be seriously considered. These factors can be collapsed into three variables: technical feasibility, affordability (cost), and value acceptability. Technical feasibility can be measured by whether or not the solution is capable of being administered and if its cost is not prohibitive. In Canada, the passage of national hospital insurance illustrated that a universal health insurance system could be administered. In other words, a how-to model already existed, which enhanced technical feasibility. Any program of the magnitude of national health insurance raises concerns of affordability, which is a function of the cost in relation to the health of government budgets and the overall strength of the economy. In Canada at the time of passage, budget deficits were causing alarm, and the economy was facing rising inflation. Such concerns delayed the implementation of national health insurance and forced cutbacks in other health programs (Taylor, 1978, pp. 376-377). The technical feasibility of Clinton's amorphous plan was attacked from several perspectives. Frustrating its feasibility was the fact that the more compromises there were to fix criticisms, the more problems there were for implementation (Weissert & Weissert, 1996, pp. 302-- 303). Regarding costs, increasing budget woes made any plan highly susceptible to attacks concerning affordability.

As applied here, value acceptability contains two components; how well a solution fits the values of policymakers and the public. In Canada the values of the policymakers were divided. The CMA supported a subsidization policy that would retain physician control over the distribution of medical services. On the other hand, the Liberal party, and to a much greater degree the NDP, was committed to the concept of national health insurance. Most importantly, subsidization was rejected by the Royal Commission in place of national health insurance, and the Commission's plan became the working foundation of reform consideration. In the United States, there were clear divisions about the type of government intervention that would be acceptable to reform the financing of health care. While early on in the debate there seemed to be a growing consensus for some type of national health insurance among policy specialists, this cohesion quickly dissipated over matters such as financing mechanisms, eligibility, price controls, etc.

Concerning the value acceptability of the people, antistatist American ideology makes significant attempts to increase government intervention difficult, particularly within the area of health care (Kingdon, 1995). Canadian political ideology is generally more accepting of government intervention (Lipset, 1990; Weller & Manga, 1983). Further, the success of the HIDSA laid the groundwork for value acceptability for medical insurance.

Political variables include national mood, interest group activity, and turnover in government. National mood is a vague concept measured not only by surveys of the general public, but also by the perceptions of policymakers as garnered from contacts with interest groups, activists, and political elites (Kingdon, 1995, p. 156). In Canada the national mood seemed to be supportive of more government intervention in health care (Taylor, 1978; Vayda et al., 1979; Weller & Manga, 1983). Likewise, the physician strike in Saskatchewan affected the public's perception of the medical profession.

However, national mood is fickle and ephemeral. For instance, the Liberals were handed a stunning defeat shortly after the assent of the HIDSA, and the CCF/NDP lost the next election to the Liberal party after passing medical insurance in Saskatchewan. Also, even though the HIDSA was proven to be popular, and medical insurance in Saskatchewan although controversial was eventually embraced, there was still not strong electoral or polling support for the Liberal government. Making medical insurance a part of the 1965 election did not help the Liberals out of a minority government, as they only won two more seats, and a public opinion poll did not show strong support for making medical insurance compulsory (Taylor, 1990, p. 148). Overall, Canadians seemed to be supportive of existing plans of government intervention and for reform, but ambivalent about how medical care insurance should be implemented.

In the United States, there was strong sentiment, as indicated by several polls, that the national mood was supportive of reform. This was probably more reflective of malaise caused by the recession in 1991, which began to dissipate even before Clinton assumed office. Following the issue-attention cycle, the public's attention was not sustained for long through the complicated discussion over the seemingly intractable problems of health reform. As the economy turned around, attention turned elsewhere to other concerns such as crime and deficit reduction (Weissert & Weissert, 1996). More evidence that the national mood was not strongly for reform lies in the defeat of the Democrats in the 1994 elections, where the Republicans gained control of Congress for the first time in decades.

Interest group activity shapes the political stream as significant opposition to proposed legislation and comparatively weaker or divided support decreases the likelihood that the political stream will converge with the other streams. In Canada, powerful and entrenched interests, including the CMA and the Canadian Health Insurance Association, heavily attacked the recommendation of the Royal Commission. Opponents within the medical profession and the insurance industry framed the issue of national health insurance in terms of capitalism and choice versus socialized medicine (Taylor, 1978), but the physician strike in Saskatchewan affected the opposition's political maneuverability and public perception. On the other hand, consumer-interest groups, such as the Canadian Labour Congress and the Canadian Federation of Agriculture, criticized the medical profession and the insurance industry for their opposition to the Commission's recommendations. These groups had strong support bases and were important in countering the medical and insurance industries (Taylor, 1978).

In the United States, while former oppositional interest groups such as the AMA were actually calling for some type of reform, several groups, e.g., the NFIB and the HIAA, became fierce opponents as the Clinton plan materialized. Overall more than 1,000 interest groups became involved, and the Center for Responsive Politics declared that lobbying effort, with respect to money and the number of people involved, was the biggest ever (Weissert & Weissert, 1996, p. 100). Strong opposition to reform, coupled with endless demands by various interests, and several veto points within the system, made the interest group composition inimical to reform.

A change in administration is one of the most powerful effects on turnover. This is quite clear in Canada as a new progressive Liberal leadership, support of the NDP, and appointments of supportive cabinet ministers led to an opening of a window of opportunity and eventual passage of national health insurance. Some of these new members of the administration acted as key policy entrepreneurs in the passage of both the HIDSA (i.e., Martin) and national medical insurance (i.e., LaMarsh and Gordon). In both cases these entrepreneurs skillfully worked legislation through windows of opportunity. In the United States the 1992 election of Clinton did not lead to a strong showing of Democrats in Congress. Clinton clearly did not have the numbers and key policy entrepreneurs in Congress to push his proposal.

There were two other important variables that stand out in the case analysis-spillover and the role of political structure. In Canada, the acceptance of a federal role in health care was instrumental in the passage of national health care. Provinces in Canada have more power in Canada's federal system than states do in the United States. They were able to develop provincial plans without federal intervention and later lobby the national government for help financing the popular programs. In the United States, there was some spillover in moving toward an acceptance of a stronger federal role, but the spillover was complicated by an enmeshment of the federal government in health care through Medicare, Medicaid, and ERISA.

The different legislative-executive relations also influenced the streams. In Canada, because of centralized executive control within the legislature, once the streams merged, passage was expedited. Also, Canada's parliamentary system of government allows for a greater role for third parties, which can, as seen here, be a critical component in the opening of a window of opportunity. In the United States, the split between the executive and legislative branches makes it necessary for windows of opportunity to be strong, so that through political maneuvering policy entrepreneurs can forge important coalitions necessary to circumvent institutional veto points.

While MS informs these two cases, how does the analysis here affect the larger development of the MS lens? First, the replication of the MS lens over time and political structure illuminates its dynamic nature and provides important support for its validity. In Canada the idea of national health insurance had been around for decades before the problem and political streams finally provided a window of opportunity, but all of this was incumbent upon the role of spillover. Second, if the MS lens is going to be applicable in a comparative context, it must take into consideration the impact of political structure. As seen here, the degree of centralization in legislative/executive relations and federalism were important in shaping the flow of the streams. In the United States, the centripetal forces of federalism mitigated the impact of spillover. In Canada, the centrifugal forces deepened the impact of spillover. Third, the MS lens is able to absorb several competing theories of the policy process. In this application the lens illuminated the importance of power differentials among interest groups. The variables of national mood and value acceptability of solutions arguably reflect the concept of ideology. As seen here, an institutional analysis can also be incorporated into MS.

Examination of the streams illuminates the importance of class structure. Problems in the United States were largely confined to the lower class strata, a group that is not well supported in the political system. This affected how the problem was defined and also the solution. The business and medical industries couched the definition in terms of rising costs and wanted reform built around controlling costs. Others wanted to consider not only problems of cost but also of access. In the policy stream the debate centered around whether reform should focus on cutting costs and consequently increasing access, or should access be the most important priority with costs being reduced by increased access. Class politics was also evident in Canada, where there was a very intense ideological war along class lines pitting the medical and insurance industries against social democratic policy.

In conclusion, the MS lens describes the complex and largely unpredictable forces within the policy process that are generally necessary for the passage of controversial policy. There are other underlying factors such as institutions, interest groups, ideology, and class structure that drive the policy process and cannot be ignored. However, focusing on the underlying forces misses the importance of critical elements shaping the policy process.